UCONN Emergency Medicine Interest Group

Archive for February, 2012|Monthly archive page

EM Images #10

In IMAGES on February 25, 2012 at 11:11 AM

Syndicated from the UCONN EM Residency website; credit to Dr. London for images and text.

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A simple question: what is the diagnosis for these patients?

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Web Spotlight 2: Free Emergency Medicine Talks

In REVIEWS on February 17, 2012 at 6:18 PM

Free Emergency Medicine Talks
Format:MP3 storage site.
Author: Joe Lex of the Temple University Hospital EM program.
Audio/visual media?: yes, audio online.
Recurring features: Joe’s “pick of the week”, a single talk highlighted (you guessed it) weekly.
Why you should check it out: pretty much as much audio content as you could possibly stand to listen to, and then some, on a huge variety of topics that are well-organized by tags corresponding to the subject (e.g. critical care, endocrine emergencies, resuscitation, radiology, toxicology, wilderness medicine, etc.). The range and depth of the lectures is so broad that there’s pretty much no topic in EM that isn’t covered. Lectures and talks are generally either 30 minutes or 1 hour in length, either one-offs or as part of a collection from national/international conferences.

Connecticut Toxicology: Plant Edition

In CONNECTICUT TOXICOLOGY on February 8, 2012 at 3:34 PM

Feed me Seymour, feed me!

The latest modules of Connecticut Toxicology have been released! Access them by clicking on the “Connecticut Toxicology” section header above, then scrolling down past the introduction/cover letter to the module that you want to take. These modules are all about plant life– from a general approach to their identification, to several individual poisonous or otherwise unpleasant plants. Did you ever wonder what would happen if you ate those berries that mom always told you to stay away from? Learn all about it by taking the modules! This is part of my selective project, and your help, by means of taking the surveys and reading through (or listening to) the modules would be much appreciated.

This is also the last group of modules to be released, meaning that the Connecticut Toxicology project is now completely published and available. Please feel free to explore!

Upcoming meeting: IMPORTANT!

In ANNOUNCEMENTS on February 5, 2012 at 6:08 PM

The next EMIG meeting has been scheduled for Monday, February 27th from 6-8 PM at Dr. Regan’s. Further details available by contacting lburns@up.uchc.edu. The subject is:  “What do I do as a 4th year if I’m interested in EM”. Both faculty and current 4th year students will be there to discuss tips on how to plan your 4th year, specific residency programs, and other tips. This meeting is HIGHLY recommended if you are a 3rd year that is interested in EM.

Off Service #3: Critical Care

In OFF SERVICE on February 4, 2012 at 5:19 PM

I’m in the ICU this month, where acid-base disorders are more the rule than the exception. One issue that frequently comes up is metabolic acidoses and the specter of mixed acid-base disorders looming its ugly head. I feel this topic is frequently made overly complex, and thus ends up being ignored, when figuring it out is really not that complicated. I think this is because of the delta gap, or in Dr. Henry’s words, the “delta-delta”:

Delta-delta = (measured anion gap from labs – normal anion gap)/(normal HCO3 – measured HCO3 from labs) = (measured anion gap from labs – 12)/(24 – measured HCO3 from labs)

I think this equation gets easily confused because of the fact that the calculation involves subtraction in the denominator. Since I am not particularly facile at math at the drop of a hat (or at least, not with an ICU team as my audience), I will outline the very simple way that I have reasoned how to determine if a mixed acid-base disorder is present, in a way that should be easy to remember:

In the setting of an INCREASED anion gap metabolic acidosis (AKA an anion gap metabolic acidosis):

If there is an additional METABOLIC ALKALOSIS…

HCO3 is HIGHER than it should be, therefore…
The denominator is SMALLER, therefore…
The delta-delta is BIGGER, and…
If the delta-delta > 2, there is an increased anion gap metabolic acidosis AND a metabolic alkalosis.

If there is an additional NON-ANION GAP METABOLIC ACIDOSIS…

HCO3 is LOWER than it should be, therefore…
The denominator is BIGGER, therefore…
The delta-delta is SMALLER, and…
If the delta-delta < 1, there is an increased anion gap metabolic acidosis AND a non-anion gap metabolic acidosis.

For a more comprehensive discussion, see this selective project created by a UCONN student here.

Why should you care? Well, particularly if you are resuscitating with large volumes of normal saline (which contains a lot of chloride), the pH may not give a full indication of what is going on with the patient, and you may make changes in your management accordingly. For instance, you might want to switch to Lactated Ringers as your IV fluid.

Click below to see a BONUS section on patients with hypoalbuminemia, and how not to miss metabolic disturbances in this population!

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