Red Man Syndrome

RMS is a rate-dependent infusion reaction to vancomycin. The anaphylactoid reaction is from direct mast cell degranulation by vancomycin and subsequent histamine release. This results in pruritis, erythema, and flushing over the head/neck and upper torso. Anaphylaxis occurs via IgE and is less common than RMS with vancomycin.

So give antihistamines (diphenhydramine, ranitidine) and stop the infusion. Treat hypotension with fluids. After symptoms resolve, restart vancomycin at a slower rate (varies based on severity of symptoms). Consider true anaphylaxis if symptoms do not resolve and give epi and steroids.

Sources

Rosh Review

LIFTL

Uptodate

Umbilical Cord Prolapse

Umbilical cord prolapse is an emergency more likely in cases of shoulder or breech presentations. The umbilical cord will be visible protruding from the cervix on your exam. Compression of the cord will block fetal circulation. There are a few things to think about while getting this person an emergency c-section.

1 - Trendelenburg or knee-to-chest position 2 - Lift the presenting part of the baby off the cord 3 - Tell mom - don't push

Do not manipulate the cord as there is risk for vasospasm.

Sources Rosh Review First 10 EM https://first10em.com/2015/03/07/the-difficult-delivery-umbilical-cord-prolapse/ emDocshttp://www.emdocs.net/the-complicated-delivery-what-do-you-do/

Emergency Department Thoracotomy Indications

EDT is resource intensive and frequently futile. There is controversy regarding the procedure, with varying guidelines and reported survival rates.

Signs of life - pulse, bp, spontaneous respirations, reactive pupils, extremity movement, cardiac electrical activity

EAST guidelines for EDT

1. Strong recommendation if pulseless w/ signs of life after penetrating thoracic trauma
2. Conditional recommendation if

•  Pulseless w/o signs of life after penetrating thoracic trauma
•  Present OR absent signs of life after penetrating extrathoracic trauma
•  Present signs of life after blunt trauma

    3. Recommendation against if absent signs of life after blunt trauma

  

Exam world answers

1. penetrating trauma w/ witnessed prehospital or ED arrest
2. penetrating trauma w/ SBP <70 after fluid resuscitation
3. blunt trauma w/ ED arrest

Why are you doing EDT?

1 - Cardiac tamponade release 2 - Cardiac massage 3 - Intrathoracic/cardiac hemorrhage control 4 - Cross-clamping descending aorta (optimize cerebral/coronary perfusion) 5 - Control air embolism

Sources

Wiki EM EM updates Medscape LIFTL