What's The Pathogen?

66 year old male presents with high fever, nonproductive cough, nausea, vomiting, diarrhea, and headache.
On exam, patient is febrile to 103 F and tachypneic, with heart rate of 77.  He appears ill and somnolent. He is complaining of a headache and abdominal pain. Rales noted in LLL.
Labs are significant for a WBC of 15 with 90% PMNs, sodium 126, AST 126, ALT 140, ESR 98.
CXR shows patchy alveolar infiltrates with LLL consolidation.
What's the pathogen?
BONUS: How to make the diagnosis?
Answer in the comments section or email j_racusin@yahoo.com

Pearl of the Day!

When calculating anion gap in a hyperglycemic patient, use the measured serum sodium, NOT the corrected serum sodium.
Or does everyone know that, like,duh, in which case, my apologies.

This just in: Modified Valsalva for SVT

A variation on the Valsalva maneuver for converting SVT, sent in by Mike Kiernan:
https://www.youtube.com/watch?v=8DIRiOA_OsA
In this video by the Lancet, Valsalva x 15 sec followed by placing patient supine with legs elevated increased rate of successful cardioversion. They also have a pretty cool way for the patient to perform the Valsalva maneuver.
Hat tip to MK!https://www.youtube.com/watch?v=8DIRiOA_OsA
*Please let me know if clicking on the link does not work!*

Neonatal O2 sat

We interrupt the regularly scheduled ACEP posting to bring you this tidbit from AudioDigest Emergency Medicine:
When measuring SaO2 on a newborn, it takes 10 minutes for the SaO2 to reach 85-95%.
Avoid hyperoxia, this may cause tissue and organ injury due to free radical formation. Start with RA or blended O2.

In addition, studies show that bundling an infant raises the skin temp but not the rectal temp, except in infants 1-2 days of age.
A neonate with rectal T >100.4 F at home warrants a workup even if afebrile in the ED.

Courtesy of Phyllis L. Hendry, MD "Emergency Presentations in the First 28 Days of Life"

ACEP 2015 Pearls Part 1

I'm starting a series of practice-improving information that I learned at ACEP 2015.
The first few in the series are from David Pearson, MD, FACEP, Associate Residency Director, Carolinas Medical Center and his "Critical Care Pearls" session.
*Shock Index: A better predictor of shock than SBP alone. According to Dr. Pearson, a SBP< 90 is actually a late and insensitive finding.
The shock index is HR/SBP. A value > 0.9 indicates tissue hypoperfusion.
4% of intubated patients have peri-intubation cardiac arrest and the shock index can predict risk of peri-intubation arrest
A preintubation shock index of 0.8 or higher predicts post-intubation hypotension and peri-intubation cardiac arrest
Other predictors include intubation for acute respiratory failure, chronic renal insufficiency, and advanced age
*Fluids: A balanced electrolyte solution is more physiologic than either LR or NS.
pH of NS= 5.5
pH of LR= 6.5
Balanced electrolyte solution, eg. Plasmalyte: pH= 7.4
With NS, chloride is exchanged for HCO3- in serum which can lead to acidosis and hyperchloremia
In severely ill acidotic patients, NS can further drop pH
In absence of BES such as Plasmalyte, LR has higher pH and is more physiologic

More pearls from Dr. Pearson's session coming soon!
Feedback is appreciated! Hope this is helpful.

**CORRECTION: The original post incorrectly attributed this session to Dr. Scott Weingart. The author apologizes for any inconvenience/misunderstanding.

Useful Tips from Colleagues...

Here are some helpful tips from colleagues, from the May 10 staff meeting.

*To remove embedded tick mandibles after the rest of the tick has been removed, use an 18 gauge needle in a scooping motion and they will easily come out. (T.Y.)

*In a patient with suspected subclavian thrombosis: With patient's hand in dependent position, most patients will have distended veins. Have the patient raise the hand above the level of the heart and the distended veins should collapse. If not, this raises suspicion for an upper extremity/subclavian DVT (B.P.)

*Carotid dissection: causes stroke/TIA symptoms in younger patients (causes 25% of strokes in this population!) Exam findings may include facial or neck pain/tenderness, ipsilateral Horner's syndrome, monocular blindness. CTA is test of choice for diagnosis. (A.Y.)

* Emedhome.com is a good website for emergency physicians, to subscribe is $99/year. (M.K.)

*A monoclonal antibody to reverse Pradaxa in major bleeds (Praxibind) is coming to Porter! It is specific only to Pradaxa. It's not cheap. (T.Y.)

Feel free to submit any other pearls of wisdom that you'd like to share. 

Hello!

This blog is meant for Porter ED providers to share knowledge about anything they might have learned at conferences, workshops, etc. or through experience, that the rest of us might find helpful. Even links to other websites or useful journal articles.

I'll give an example here.

My usual migraine cocktail (for people without "allergies" to Toradol, Reglan, water, all narcotics except Dilaudid, etc.) consists of (all medications given IV):

Toradol 30 mg

Reglan 10 mg

Benadryl 25-50 mg

Dexamethasone 10 mg +/- NS 1 L
Recently I discussed a case of complex migraine (headache + focal neuro s/s) with the attending neurologist at UVMMC who recommended for refractory migraine adding 1 gm Magnesium Sulfate IV. This wasn't something I've used before, but I've added it to my cocktail ingredients as a (+/-). Too early in the game to conclude if it makes a big difference or not, but it's worth a try (assuming reasonable renal function)! 
Add to the list of the many uses for magnesium!
Hope this is new and/or useful to at least some of you. Feel free to share what works for you for your migraine patients.