systemet

Unconscious patient, who's diaphoretic, with no history available, other than a medic alert reading "IDDM", who's vital signs are "normal", with a bG of 120 mg/dl (6.7 mmol/L). What am I thinking? - I can't rule out a traumatic etiology. I can't apply NEXUS / Canadian C-spine rule. Thus the patient gets immobilised. - I'm concerned about this patient's ability to control their own airway, and their aspiration risk, if they're GCS 3. I'd be considering advanced airway management. - In the absence of respiratory depression naloxone is unlikely to be of benefit. - I'd love a 12-lead along the way. - This could be about a billion things more likely than (1) relative hypoglycemia, or (2) an equipment error. With a glucometer reading 6.7 mmol/L, I'm not giving D50W. Otherwise shouldn't I'll be giving D50W to every patient with a GCS of 3. And that's just silly. Perhaps I should push tenecteplase on everyone with chest pain and isoelectric STs, just in case there's an equipment error with the LifePak?

So's your hat.

Hi, I just wanted to comment on this, a little. The idea that autism is caused by MMR vaccination is no longer a matter of serious scientific debate. Since Wakefield's original study of 12 children [1], a huge amount of money and resources has been devoted towards investigating this idea. There has been a total failure to demonstrate any causal link between the MMR vaccine and autism. In fact, there's been pretty good data reported to suggest that the two are not linked. For example: - a study of 32,000 children in Yokohama, Japan born between 1988 - 1996, showing that not only did the diagnosis of autism fail to drop after MMR vaccination stopped in 1993, but that it continued to increase at a greater rate [2] - a Polish study of 288 children, failing to show an association between either MMR or single-dose measles vaccination and the development of autism [3] - a Danish study of 537,303 children, failing to show any association between autism and MMR vaccination [4] This is by no means an exhaustive description of the epidemology that's been performed. And this alone, should really lead anyone to question any proposed link between MMR vaccination and autism. If you can't see an association in a half-million Danish children, it's probably not there. It's certainly better scientific evidence than a case-series of 12 autistic patients. The science alone, answers this question. There is no longer any serious debate. On top of this, is the issue that Wakefield, the physician who first proposed this link has had his medical license revoked for fradulent and unethical behaviour, and that the Lancet has retracted his initial publication, referenced in [1]. What's important to understand, is that this did not occur because Wakefield was wrong. People are wrong in science all the time. Sometimes spectacularly wrong. I would be suprised if it's even possible to complete a career as a scientific researcher without ever printing something that was later shown to be incorrect. Being wrong is accepted, perhaps even encouraged in science. Provided you behave ethically. Wakefield was being paid by a law firm developing a law suit before he published his study. He even proposed a link between MMR vaccination and autism before carrying out his original research. He misrepresented his patients, and reported his data incorrectly [5]. What's unforgiveable, is that this fradulent action resulted in the diversion of an extraordinary amount of scientific resources towards investigating a hoax. There's no doubt that this money, time and effort could have been better spent elsewhere. Furthermore, the declining rates of MMR vaccination that happened in response, likely resulted in many childhood deaths from preventable disease. All the best. [1] Wakefield AJ, Murch SH, Anthony A, Linnell J, Casson DM, Malik M, Berelowitz M, Dhillon AP, Thomson MA, Harvey P, Valentine A, Davies SE, Walker-Smith JA. Ileal-lymphoid-nodular hyperplasia, non-specific colitis, and pervasive developmental disorder in children. Lancet. 1998 Feb 28;351(9103):637-41. [2] Honda H, Shimizu Y, Rutter M.No effect of MMR withdrawal on the incidence of autism: a total population study.J Child Psychol Psychiatry. 2005 Jun;46(6):572-9. Przegl Epidemiol. 2009;63(1):107-12. [3] Mrozek-Budzyn D, Kiełtyka A, Majewska R.[Lack of association between MMR vaccination and the incidence of autism in children: a case-control study]. Przegl Epidemiol. 2009;63(1):107-12. [4] Madsen KM, Hviid A, Vestergaard M, Schendel D, Wohlfahrt J, Thorsen P, Olsen J, Melbye M.A population-based study of measles, mumps, and rubella vaccination and autism.N Engl J Med. 2002 Nov 7;347(19):1477-82. [5] Deer B. How the case against the MMR vaccine was fixed. BMJ. 2011 Jan 5;342:c5347. doi: 10.1136/bmj.c5347

I think the interpretation kind of hinges on whether this is artifact or fibrillation. Could be either: (1) Atrial fibrillation with 3rd degree AV block with a ventricular escape pacemaker, if this is fibrillation Or (2) Idioventricular rhythm (if you think the notching is just coincidental, and the isoelectric line is just artifact) OR (3) Junctional bradycardia (if you think the notching is retrograde P waves, and the isoelectric line is just artifact) The patient sounds remarkably stable. If there was a 'lyte problem last time, causing a bradycardia, there might be a 'lyte problem again. Perhaps caused by a UTI (foul-smelling urine?). Has there been recent urine output? Is it possible there's a renal infection and acute renal failure? Sepsis? Perhaps an infarction? What's her history like? It seems like a good time to have a chat with the family about what there goals are for hospital care at this point. If she has a DNR, etc. If they want it treated, then an ER trip seems justified, but I don't know if I'd treat beyond IV fluids (if she appears dehydrated) if she's asymptomatic. Is she asymptomatic? Because there's no orthostatic intolerance, and she's AaOx3, how exactly do the family feels she's "not acting right"? Is there any suspicion of a CVA?