At the Los Angeles County-University of Southern California Medical
Center, we operate a hyperbaric chamber for the treatment of diving
injuries. Our chamber is located on beautiful Santa Catalina Island off
the coast of Los Angeles. When patients are triaged to the chamber via
Baywatch (that’s right, our EMS providers out on the coast are actually
referred to as Baywatch!), our faculty and residents fly out by
helicopter from the Medical Center to meet them at the chamber.
Dr. LoPresti has a knack for making sense of thyroid emergencies.
You’ll remember from last month that he used the term “decompensated
hypothyroidism” instead of myxedema coma. He explained that patients
who are hypothyroid, and thus have a decreased metabolic rate, conserve
heat by being in a constant state of vasoconstriction. That is why they
feel cool to the touch....
On the EM:RAP program, Mel Herbert and I recently did a two-part series
on two rare and exotic emergencies – myxedema coma and thyroid storm.
Our expert for this segment was Dr. Jonathan LoPresti, a senior
endocrinologist and thyroid researcher at LA County/USC Medical Center.
This is the second of a two part series on stroke syndromes. In last month’s EM:RAP column, we highlighted important differences among the various types of hemorrhagic strokes. This month, we turn our focus to ischemic stroke, which is more common, and by far the leading cause of severe disability in the developed world.
In this month’s EM:RAP, we discussed several aspects of stroke in the
emergency department. Stroke is now the second leading cause of death
in the developed world and the leading cause of severe disability. With
all of the controversy surrounding tPA in stroke, we often lose sight
of all of the other things that are equally, if not more important, in
Ahbinav Chandra and colleagues looked at 10,145 patients over two years
who had presented to multiple EDs with the complaint of chest pain.
After a negative work-up (non-diagnostic ECG changes, normal initial
biomarkers, and a non-MI impression) the EP had stratified each patient
as non-cardiac, low risk, high risk, or unstable angina, based solely
on their gut instinct. How right were they?
In general, toxic alcohols can be divided into two groups based on
similarity in symptoms, pathophysiology, and treatment: isopropyl
alcohol and ethanol in one group, methanol and ethylene glycol in the
other. Isopropyl alcohol can be considered a “super alcohol” with more
profound intoxication effects than ethanol and greater propensity for
gastrointestinal bleeding from hemorrhagic gastritis.
At a recent All L.A. Conference, a panel of guest speakers from several
emergency departments throughout Southern California discussed a few
current updates and controversies in the management of trauma patients
There are a multitude of definitions and cut-off values for the varying
degrees of hypothermia. Mild hypothermia (34 - 35C or 93.2 -95F) is
considered the excitation phase wherein shivering occurs and cardiac
output increases. In moderate hypothermia (30 - 34C or 86 – 93.2F) the
adynamic phase, cardiac output begins to drop.
D-dimer assays have been previously hypothesized to be useful for many
disease entities including pulmonary embolism, disseminated
intravascular coagulation (DIC) and subarachnoid hemorrhage (sampled
from the CSF). Now, D-dimer is being considered for the evaluation of
possible aortic dissection. 10 in 100,000 Americans will experience an
aortic dissection annually with 38% being misdiagnosed initially.
Clearly, we need help making this diagnosis. However, is D-dimer the