What are the indications for inotropic agents (dobutamine and/or milrinone) in treatment of acute decompensated congestive heart failure?

• advanced systolic heart failure (reduced left ventricular ejection fraction) with marginal systolic blood pressure (less than 90 mmHg)
• advanced systolic heart failure with intolerance or minimal responsive to intravenous vasodilators and/or diuretics 

Source 

Colucci, W.  "Treatment of decomensated heart failure: Components of therapy"  Up to Date.  2012 Nov. 

What are some clues to help distinguish viral from drug-induced exanthems?

It is often difficult to distinguish but here are some clues ...

• viral exanthems often have associated fever, malaise, sore throat and conjunctivitis; although drug reactions may have these features also
• viral exanthems happen more frequently in children; although adults can get them too 
• a rash that develops within 3 days of a drug being initiated for an infection is more likely secondary to the infection because of the time required for hypersensitivity to develop in a patient not previously sensitized to a particular drug

Selected infections and Other Conditions that Often Include an Exanthem and Characteristics that Help Differentiate Them from an Exanthematous Drug Eruption.  (click image to enlarge)

Source

 Stern, R.  "Exanthematous Drug Eruptions"  NEJM.  28 June 2012.

For treatment of burns, why might bacitracin be favored relative to silver sulfadiazine even though its antimicrobial coverage is less broad?

because silver sulfadiazine causes:

• allergy in patients with sulfa sensitivity
• permanent silver staining of the skin and therefore should not be used on the face or other cosmetically sensitive areas
• severe hemolysis in patients with G6PD
• sulfonamide kernicterus in children less than 2 months and therefore should be avoided in pregnant women, newborns and nursing mothers

Source

Hall, R., Watts, L., and Bashiti, S.  "Thermal Burns"   Critical Decisions in Emergency Medicine.  March 2012.

What is the treatment of hemolytic-uremic syndrome (HUS) and thrombotic thrombocytopenic purpura (TTP)?

Plasma exchange.  This will remove antibodies to a von Willebrand factor-cleaving protease (ADAMTS13), deplete very high circulating levels of von Willebrand factor (VWF) multimers, and replace the missing protease (ADAMTS13).   If there is a delay in initiating plasma exchange, give FFP which contains ADAMTS13.

Consider the diagnosis of HUS and/or TTP when there is unexplained thrombocytopenia (typically less than 20K) + microangiopathic hemolytic anemia (MAHA) [schistocytes, normal PT/PTT, elevated LDH, elevated indirect bili, dereased haptoglobin)


Source

Kaplan, A. and George, J.  "Treatment of thrombotic thrombocytopenic purpura and hemolytic uremic syndrome in adults"  Up to Date.  Jan 2013.

Sabatine, M.  Pocket Medicine: The Massachusetts General Hospital Handbook of Internal Medicine.  3rd ed.

How should the hypertensive pregnant patient be evaluated and treated?

First ask, what is the gestational age?

• if less than 20 weeks and blood pressure greater than 150/100, start antihypertensive medication in consultation with obstetrics.   Mild hypertension should not be treated as it does not decrease adverse events. 
• if greater than or equal to 20 weeks and blood pressure greater than 140/90, test urinalysis.  If greater than 1+ protein in UA, patient has preeclampsia or associated complication (ecalmpsia, HELLP syndrome); check CBC, basic chemistries, LFTs, uric acid, d-dimer, fibrinogen, coags and consult OB.  

Source 

Deak, T. and Moskovitz, J.  "Hypertension and Pregnancy"  Emerg Med Clin N Am.  Nov 2012. 

Does presence of an elevated anion gap mean that there is a metabolic acidosis?

Generally yes but not always.  Aside from the organic metabolic acidoses, an elevated anion gap can also be caused by hyperalbuminemia, hyperphosphatemia or presence of an anionic paraprotein (IgA monoclonal immunoglobulin) but given that these are fairly rare occurrences, once ruled out,  metabolic acidosis is the presumed etiology of an elevated anion gap.


Source

Emmett, M.  "Serum Anion Gap in Conditions Other than Metabolic Acidosis"  Up to Date.  Nov 2012.

What maneuvers may help you manage a shoulder dystocia during vaginal delivery?

Shoulder dystocia occurs when the anterior shoulder of the infant can't be delivered under the pubic symphysis.  Several maneuvers may be helpful.

1. McRoberts:  Mother's hips are placed in hyperflexion against the abdomen while being slightly abducted and externally rotated. Position can be augmented by 2 assistants with each holding one of the patient's legs. 





2. Rubin I: Downward pressure is applied just proximal to the symphysis pubis.  Pressure can be applied continuously or in a rocking motion. Success is increased when combined with McRoberts maneuver. 





3. Rotational:  Rotate infant slightly clockwise or counterclockwise to try and free up and subsequently deliver the anterior shoulder. If this doesn't work, consider rotating the infant 180 degrees and trying to deliver the posterior shoulder first. 








4. Manual delivery of posterior arm:  Insert hand into the vagina and flex the posterior arm of the fetus, bringing it across the chest. The posterior arm is then delivered over the perineum which allows the provider to rotate the fetus to allow delivery of the anterior shoulder once the rotation has disimpacted it from the pubic symphysis.  





5. Gaskin Position:  Place mother in a hands-and-knees position, "on all fours."

Here's a video that puts it all together ...

Sources

Image Source (McRoberts):  http://altair.chonnam.ac.kr/~tbsong/medical/sh-dyst/McRoberts.htm

Image Source (Rubin I): http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2009/dec16_6(suppl1)/Pages/18.aspx

Image Source (Rotational): http://shoulderdystociainfo.com/resolvedwithoutfetal.htm

Image Source (Manual delivery of posterior arm): http://www.glowm.com/resources/glowm/cd/pages/v2/v2c079.html

Image Source (Gaskin):  http://www.sciencedirect.com/science/article/pii/S0889854505700899

Video Source: http://www.youtube.com/watch?v=YB3_fPhgmUM

Silver, D. and Sabatino, F.  "Precipitous and Difficult Deliveries"  Emerg Med Clin N Am.

Roberts, J. and Hedges, J.  "Emergency Childbirth"  Clinical Procedures in Emergency Medicine.  2010.