ERDoc

Never trust a PA :twisted: (Just kidding, before anyone gets offended).

Incorrect. Neither has anything to do with BSA. They are differentiated by biopsy results.

Let's face it. Every medication has lots of side effects listed. how many do we really see? How many serious side effects do we really see? The way a side effect gets put on the box is a problem at times. During clinical trials, pts are asked to report any symptoms that they develop. So a huge list of side effects is created, including the ones that were not related to the medication. Let's say that drug X is in phase 3 trials. You are part of this study and happen to develop diarrhea from the native water you drank on your trip to Mexico. If you report that you developed diarrhea, even though it had nothing to do with the med, it will be listed as a side effect. The more serious side effects are very rare, and yes you should think about them when you give a med, but they should not interfere with proper pt care. There is no way to predict who will develop certain side effects. Don't live in fear of the meds or you will not give them when needed. Someone had mentioned that Zofran was not designed to treat nausea, but only prevent it when given prior to chemo/surg. Funny thing is, it works great even after a pt develops nausea. I've seen it work in pts who had no effect from phenergan. It works great in pregnant women with hyperemsis gravidarum. There are lots of meds out there that were not designed to do certain things, but we use them to do other things. Phenergan (and most of the antiemetics for that matter) were never designed to treat migraines, but they sure are efficient at it. You will never see trials for FDA approval for things like this because it is costly and most physicians know about it already. Windsong, I'm not usre what exactly you are getting at with the story, but it was a little confusing. Obesity is not caused by "poisons." Just like VS said, there are a few other issues with this story. If you want some intelligent conversation, please reprint it and clear up some of the vague parts and let us know what exactly it is you want to know. NREMT-Basic, you show that you are not "schooled in research methodologies." NO ONES opinion is considered a valid form a research. They are only what you said they are, opinions. As we all know, opinions are like arseholes, everyone has them. Most experts base their opinions on solid research (maybe this is what you were getting at). Research involves carrying out an unbiased study and examining the data to come to a conclusion. The whole idea of research is to avoid people's opinions and biases (including the so-called experts). Before you attack someone, make sure that your facts are correct. I have gotten far enough in Uni to know plenty about research methodologies, including designing and carrying out a study or two of my own. If you want to have an intelligent conversation about research methodologies, let me know, I will be more than happy to go over the topic a little (although, I think someone may have discussed the different types of studies on another threat). As Bushy said, case studies are the least useful form of study. As Rid said, there are much worse drugs in your bags that you should be concerned with. Adenosine comes to mind. ANy drug that stops someones heart for a period of time tends to tighten the sphincter a little.

I would keep him NPO. Treat as you would any other burn pt. The flame isn't going to cause a fire in the airway, but a burn will be a problem.

At the place where I did my residency the surgeons scoffed at those who feared sux in a burn pt. They felt that if the pt was being monitored properly that you should pick up any K problem and fix it before it became an issue. They said that if you could not do that you were not properly montioring the pt. In the field and in the ER for that matter, you will not see the affects of sux on potassium, it is a delayed issue that the ICU teams have to deal with. I had a burn pt that set the bed on fire while he was smoking some crack. Burned pretty much his entire back from top to bottom. He was relatively calm in the helicopter. As soon as he got to the ER the adrenalin must have shut off and the pain must have kicked in, because he was trying to jump off of the strecher. There was no way we were able to assess the airway. We basically intubated him just to get him to lay down. Turned out it was the right call. He had soot in his nose and mouth. About 30 minutes later a CT showed that the airway had swollen completely and the only opening was the ETT. We we were getting ready to put him down, we asked the surgeon that there what he would prefer to have us use instead of sux. He said that sux was fine and that he could deal with the potassium later. Granted it is anecdotal, so take it for what it's worth. Oh yeah and follow your local protocols.

Erythema Multiforme(EM), Stevens Johnson Syndrome(SJS) and Toxic Epidermal Necrolysis(TEN) are all believed to represent the same disease process over a spectrum of severity, although there is great debate about this as some people believe that they represent different diseases with similar symptoms. The least serious is EM which is basically just a rash with possibly one mucosal (lips, mouth, anus, rectum, GU tract) surface involved. SJS is the next severe. It involves at least two mucosal membranes. These pts can be very sick, and even septic because of the exposed skin. They should be treated as burn pts. The most severe is TEN where you actually get necrosis of the epidermis. These are the sickest. Any of these can be caused by drugs(anticonvulsants, NSAIDs, antibiotics, Allopurinal and steroids being the most common), viruses or it can be idiopathic. For the prehospital environment, fluids and pain control are your treatment. Emedicine has a few good article and pictures for your enjoyment (I'm too lazy right now to provide the links, sorry).

Brock, I believe these are what you are trying to describe. Let me know if I am wrong and I will delete these so that I don't throw anyone off. Also, looking over the thread again, I have a question. Brock, why exactly did this guy or his wife call the ambulance? Did he have another seizure or was it for the rash? Someone had mentioned sepsis. Sepsis is definitely a possibility (especially with those VS), but what is causing the sepsis, anyone besides Brock? Do you need to use full PPE for transporting this pt? Why or why not? Let's recap a little here: You have an adult male who developed new onset seizures about 3 weeks ago and was started on phenytoin. About 1 week ago he developed a rash on his trunk and arms that looks like small targets. He was started on Bactrim for the rash and there has been no improvement. There is a questionable fever. He is hypotensive and tachycardic. He also has lesions in his mouth. This is a complicated case because there is so much going on. You have to sort through the details and figure out what is important here and what is just a red herring. This is probably something you have not learned about in EMT class. It is something that can be considered an emergency and although there is very little to do for it in the field it may determine where you take your pt. Hope I havne't given away too much here.

Playing devil's advaocate, if you are thinking chicken pox, are you also thinking small pox? If not, why not?

Who said this guy had a fever? His temp was 99-100. This is normal diurnal variation in temp. A fever is anything 100.4 and over. People probably have not asked about vitals because we are still collecting the history. Something that might be helpful in this case is a picture. Is there anyway you can do this without giving the case away? Unfortunetly, when described with words a lot of rashes sound identical, but when you see them, well, a picture is worth 1,000 words.

What kind of workup has been done for the seizures? Let's hear a little more about the sores on his hands. Are they on his palms? Describe the rash on his chest. Any joint pains, fevers, penile discharge? What happened before the seizure?

In my experience Zofran is a little better at controlling nausea than phenergan. The problem is that Zofran (especially IV) is much more expensive. Whenver I order Zofran (IV or ODT) in the ER I can hear the beancounters cringing upstairs. It has gotten to the point where we get occasional nastygrams reminding us how much zofran costs. I like phenergan because of the sedative side effects. It works great on drug seekers, they are usually so out of it that they don't ask for more meds . Just to take the topic off track again, where I am currently at, if you come in and c/o pain most docs give you 2mg dialudid and 12.5 of phenergan. No wonder we have such a large drug seeking population ( :evil: ARGH!!). Nothing like being the candyman. Needless to say that I am not well liked among our seekers. I never give out dilaidid, unless there is true pathology.

But I've got much respect for the IM guys. They are some of the brightest people. Where else can you perseverate for 2 hours over whether a pt should be on an 1800 or 2000 cal diet?

I guess I should give it up. This kid was suffering from a migraine variant, similar to a confusional migraine. He had an MRI and EEG which were both normal. He was dc'd from the ER and when he woke up the next morning was perfectly fine, except not being able to remember the events during the migraine, including the 4 hours he spent in the ER. Not all migraines present with the typical symptoms. There are several unusual versions including abdominal migraines and cyclic vomiting. Emedicine has a good article on the different kinds of migraines if I remember correctly. It was definitely an interesting case to see.

Find a good doctor.

First off, how was this diagnosis made? You can get fungemia, but these people are generally pretty sick and immunocompromised. Here's a Wiki reference for you http://en.wikipedia.org/wiki/Fungemia Hope this helps a little.

WBC 8.6 H&H 14/39 Plt 189 Na 138 K 4.2 CO2 21 Creatinine 1.1 ALT and AST wnl UA and drug screen neg CT read by radiologist as normal EKG NSR with no delta waves, normal PR interval, otherwise normal. Someone mentioned INR, his is 1.0 Anyone have it figured out yet? The correct answer has been mentioned already.

You are correct, he cannot remember them after 5 minutes. No known chemical exposure. No weight changes. Eats well, vitamins probably not an issue. Not taking any steroids.

His blood sugar is 96.

No family history of cancer or neuro problems, no allergens. I don't know what position he plays on the team. As far as the parents know there have been no other changes in behavior or memory. He has had a cold or two over the past year, but has otherwise been healthy. He is A&OX3, answers appropriately without delay. His speech is not rushed. He his fully coherent. Yes, he is embarrassed because he knows that he should remember things, but cannot. No funny sensations. He is a white kid from an upper middle class family. Their house is clean and relatively new (no lead paint). There are no other contacts (at home or school) with similar symptoms. Someone mentioned an absence seizure. This is a good thought, but he is a little old for one (but hey, not everyone reads the textbook). No special diet, and not sexually active. He did not go to the state fair this year (which is in Syracuse for anyone that may be interested). To summarize, 15y/o male with sudden onset of memory loss (short term) apparently while playing soccer. No h/o head trauma and very little else for history. Does not seem to be drug or environmentally related. Moving onto the PE: VS 76 110/60 16 100%RA PERRLA, EOMI, CN2-12 intact, 2+ reflexes in all extremities, 5/5 strength in all extremities, cannot remember 5 objects after 5 minutes. No asterixis, Rohmbergs sign. Normal rapid repetitive movement, able to do finger to nose, heel to shin. Gait normal fowards and backwards. Able to count backwards by 7s. Anything else you would like to know about the PE?

Wow, are you an internal medicine resident??? He is the youngest of 3 kids, no suicidal ideations, immunizations UTD, does not take any supplements, no contacts or glasses, no night sweats or weight changes, no change in bowel habits. To save space, the rest of the answers are negative. We will cover skin tugor when we get to the PE.

Nausea and headache are symptoms, so I will be more than happy to tell you that there have been none, before and after the event on the soccer field. The parents state that he eat cereal and juice for breakfast, which is normal for him. He does not remember what he had for lunch. He has no allergies.

No family history of neuro problems. Other than the camping previously discussed, nothing exciting over the summer.

No meds, nothing OTC. No ear infections. The parents state that he might have had a tick bite during the camping trip over the summer. No one remembers any other bug bites of any significance. To answer the next question, there have been no rashes.

Agreed, but this is what the parents tell you. He does not notice any blurred spots or other visual disturbances. He says he can remember your conversation, but when you ask him to repeat it he is unable to. No history of similar episodes. There have been no recent infections.

We will come back to the physical exam. Medicine is 90% history and 10% exam.