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Good 3-5 minute read on Critical Care time complements of ALiEM- what qualifies, time frames, procedures, etc.
https://www.aliem.com/2017/07/charting-coding-critical-care-time/
Critical Care Time
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Monthly Archives: July 2017
Pantoprazole on Shortage
See below: The gist is, 40mg IV Pantoprazole (Protonix) on shortage until August or so. Consider using Pepcid instead.
Medical Staff,
Pantoprazole 40mg inj vials is on national backorder. The anticipated availability is in early August. To ensure continuity of patient care, Pharmacy, supported by P&T plan to substitute pantoprazole 40mg IV push daily to famotidine 20mg IV push BID for the indication of stress ulcer prophylaxis. And pantoprazole IV push to esomeprazole IV push for all other indications.
Pantoprazole 40mg inj vials will be reserved for existing PPI drip protocols.
The good news is that we do not have to adjust existing protocols or infusion pump library settings. Pharmacist will manually change the order from pantoprazole to alternative upon verification. We expect that this shortage will be relatively short.
Please call pharmacy with any questions or Michael Nnadi at 336-817-5265.
Narcissus: A Case Presentation
11 month old Chinese female brought with concern for two episodes of emesis after family dinner. Via interpreter phone the father explains that everyone in the family vomited after dinner at home. He states the adults all vomited once and feel fine now, but the child vomited twice and he wants to ensure she is well. He is concerned that she is sick from “the onions”. When asked to clarify he explains he made a noodle dish for dinner – every ingredient has been used previously for the same recipe except for “the onions”. He then holds up a Kroger bag of what initially appear to be green onions, with the typical long green stalks and a white bulb base – but these are covered in dirt. He explains that he found them growing in their backyard and thought he’d use them for dinner, but now suspects they have made everyone sick. A brief intradepartment search procured a gardener RN who readily identified the plants – daffodils, “they just haven’t flowered yet”.
Kentucky Regional Poison Control advised that all parts of the daffodil (genus Narcissus) cause self-limited gastrointestinal symptoms for approximately 3 hours after consumption, and that care is largely supportive. There are reports of massive consumption causing CNS symptoms in dogs, but similar presentations have never been reported in humans.
Take home points:
- Green onions and unflowered daffodils are quite similar in appearance – the classic onion odor and tearing following incision differentiates the two
- Daffodil toxidrome is self-limited, with predominantly gastrointestinal symptoms (nausea, vomiting, diarrhea). Supportive care with oral rehydration fluid is warranted in pediatric patients.
References:
- National Capital Poison Center – http://www.poison.org/articles/2015-mar/daffodils
Limping toddler
Nothing crazy here, just some EM bread and butter. I’ve had a couple of these at Children’s, and each time (with two different attendings), I’ve been told that the adult EM residents seem to overlook this, or not have any idea that it’s a thing, which is kind of embarrassing.
The patient is a 22-month-old male who presents with difficulty walking. Mom states that the child was walking fine until this morning. Since then, he has not been wanting to put weight on his right leg. Mom does not recall any injury. The child is otherwise well, no signs/symptoms of illness, and he has no medical problems.
On exam, the child will not put weight on his right leg when forced to stand. The extremity is well perfused, and there are no signs of trauma. He has no point tenderness, so it is not clear where he is hurting, but does seem to have pain when the foot is grasped and rotated internally and externally.
Discussion: In the toddler with a possible lower extremity injury, it may be difficult to localize where the child is having pain. If there is a question, the entire extremity should be imaged (though you should try to localize the problem area if possible). In this case, we suspected a toddler’s fracture, so a 3 view tib/fib was obtained. This is an important learning point: many times, the fracture line will only be visible on the oblique view, so it is necessary to get 3 views. In this patient, the xray was negative (as were other films of the leg). We diagnosed the child with a toddler’s fracture, placed him in a short leg splint with stirrups, and discharged him with orthopedics follow up.
A toddler’s fracture is a spiral fracture of the distal tibia which usually occurs by the same mechanism as an adult spraining an ankle. Sometimes it is a clinical diagnosis, not visible on X-ray. There is debate in the literature about immobilization in this case; some say it is necessary, some say it’s not. The culture at Norton Children’s seems to be immobilization. Regardless, the child should follow up in 1 week for definitive diagnosis, either with repeat plain films, or possibly MRI or bone scan. If there is a visible fracture on plain films in the ER, the child should be placed in a short leg splint with knee immobilizer and follow up with orthopedics in 72 hours.