Case Report of the Use of an Intravascular Cooling Device in the Management of Malignant Hyperthermia.

Malignant hyperthermia (MH) is a rare, life-threatening condition caused by alterations in skeletal muscle calcium channels inherited through an autosomal dominant pattern. The use of specific agents in anesthesia such as inhaled anesthetics and succinylcholine can precipitate a hyperthermic crisis. Patients experience a rapid increase in muscle rigidity, secondary to skeletal muscle calcium dysregulation, leading to acute rhabdomyolysis and possible hyperthermia. Providers must have a high index of suspicion of this disease process because early diagnosis is critical to mortality reduction. Management centers around removal of the offending agent, dantrolene, and supportive care including cooling if hyperthermic. Intravascular cooling devices have been used in thermodynamic regulation after cardiac arrest and have shown to be more effective than dermal cooling techniques; however, they have not been well described in other disease processes. The following case report is the first to describe a patient suffering from MH to undergo invasive intravenous cooling in order to counteract the effects of this life-threatening disease.

Emergency department management of patients with rectal bleeding.

Rectal bleeding accounts for approximately 1 out of every 1000 United States emergency department visits annually. The causes of rectal bleeding are broad, and can range from the benign to the life-threating. This review provides foundational knowledge on rectal bleeding as well as evidence-based recommendations for its evaluation and initial management in the emergency department. Anatomic considerations are discussed, and the differential diagnosis based on risk factors such as age and comorbid conditions is presented. Treatment recommendations based on the presumed diagnosis as well as the evidence associated with their use are also described. Decision-making, including disposition based on laboratory results, imaging studies, and application of risk scoring calculations is also discussed.

Does a non-invasive hemoglobin monitor correlate with a venous blood sample in the acutely ill?

Non-invasive hemoglobin measuring technology has potential for rapid, portable, and accurate way of providing identification of blood loss or anemia. Our objective is to determine if this technology is reliable in critically ill patients presenting to the Emergency Department. Prospective cross-sectional observational study was done at an urban level-one trauma center, 135 subjects were conveniently sampled, suspected of having active bleeding, sepsis, or other critically ill condition. Non-invasive measurements with Masimo (Irvine, CA, USA) Radical-7 and Rad-57 hemoglobin monitors were compared with the Beckman-Coulter LH-550 (Brea, CA, USA) clinical laboratory blood cell analyzer. The primary outcome was the relationship of the non-invasive device to the clinical laboratory results. Secondary evaluations included the effect of pulse rate, systolic BP, respiratory rate, temperature, capillary refill, skin color, nail condition, extremity movement. The Radical-7 was able to capture reading in 78% (88/113) of subjects, and the Rad-57 in 65% (71/110) of subjects. The correlation (R(2)) of the device Hb was 0.69 and 0.67 (p < 00.01) for the Radical-7 and Rad-57, respectively. The coefficient of variation for the Radical-7 was 18%, and for the Rad57 it was 13%. Univariate analysis shows none of the observed factors is associated with the difference values between the device Hb and laboratory Hb. Our results show that Radical-7 and Rad-57 devices do not report readings in 29% of patients and accuracy is significantly lower than reported by the manufacturer with over 50% of readings falling outside of ± 1 g/dL. We determined that none of the several potential factors examined are associated with the degree of device accuracy.