POCUS in the Critically Ill Pregnant Patient
Long head of biceps tendon (LHBT) Testing
Overhead activities can cause anterior shoulder pain due to LHBT instability. A review of 3 physical exam maneuvers for bedside evaluation.
Speed test
Shoulder at 90° of flexion with arm fully supinated and elbow extended
Patient attempts to fwd. elevate arm against a downward force
Positive test is pain localized to bicipital groove.
Sensitivity 54% and specificity 81% for biceps pathology
Yergason test
Elbow at 90° of flexion with arm fully pronated and held against thoracic wall. Examiner grips patient’s hand and resists attempts at supination.
Positive test is pain localized to bicipital groove or LHBT subluxation.
Sensitivity 41% and specificity 79% for biceps pathology
Upper Cut test
Shoulder neutral with Elbow at 90° of flexion, arm fully supinated and hand in a fist. Patient moves hand toward chin in an uppercut motion like a boxer. Examiner places hand over patient’s fist and resists upward movement.
Positive test is pain localized to bicipital groove or LHBT subluxation.
Sensitivity 73%, specificity 78%, +LR 3.38 for biceps pathology
“Push dose pressors” – administration of small doses of vasopressors in the emergency room has become a common practice. A recently published study investigated the incidence of human error and adverse hemodynamic events.
Push dose pressors were defined as:
Adverse hemodynamic event was defined as:
249 out of 1522 patients were identified and analyzed from Jan 2010 to November 2017
Adverse event
Errors
Conclusion
With a shortage of push dose epi, this may be an opportune time to review alternative options (see also Ashley's email on the subject).
The dose of vasopressor required to reverse hypotension has been most studied in pregnant women undergoing c-section who get epidurals and experience spinal-induced vasoplegia and hypotension (not necessarily our patient population, but we can extrapolate...)
Phenylephrine was found to reverse hypotension 95% of the time at a dose of 159 micrograms (a neo stick has 100 ug/mL, so around 1-2 mL out of the stick)
Norepinephrine reversed hypotension in 95% of patients at a dose of 5.8 ug. The starting dose for our norepi order in Epic is 0.01 ug/kg/min, so if you have a levophed drip hanging and have an acutely hypotensive patient, you may want to briefly infuse at a higher rate such as 0.1 ug/kg/min (for a typical weight patient), or bolus approximately 3-7 ug for a typical patient. Of course the degree of hypotension, particular characteristics of your patient and clinical context should be taken into consideration. When your a lucky enough to have this resource, always consult your pharmacist.
Bottom Line: To reverse acute transient hypotension you may consider:
-A bolus of phenylephrine 50-200 ug (0.5-2 mL from neo-stick)
-A bolus of norepinephrine 3-7 ug
-Briefly increasing your norepinephrine drip (if you have one) to something around 0.1 ug/kg/min in a typical weight patient
-Always search for other causes of hypotension and consider clinical context.
Alteplase may be considered in some patients with a presumed or confirmed pulmonary embolism. Below is a list of the different patient populations and the associated alteplase dosing.
-Hemodynamically Stable/Submassive: Alteplase usually not indicated.
-Hemodynamically Unstable/Massive: Alteplase IV 100 mg as an infusion over 2 hours.
-Cardiac Arrest: Alteplase IV/IO 50 mg bolus over 2 minutes. Can repeat a second 50 mg bolus 15 minutes later if unable to achieve return of spontaneous circulation.
Volatile inhalants such as glue, lighter fluid, spray paint are abused by "sniffing" (from container), "huffing" (poured into rag), or "bagging" (poured into bag). "Dusting" is the abuse of canned air dust removal products. These inexpensive easliy accessible products are so dangerous that manufacturers include product warnings regarding lethal consequences from misuse and even may indicate that a bitterant is added to discourage use. Common duster gases include the halogenated hydrocarbons, 1,1-difluoroethane or 1,1,1-trifluroethane which are highly lipid soluble and rapidly absorbed by alveolar membranes and distributed to CNS. Desired effect of euphoria and disinhibition rapidly occur but unwanted side effects include confusion, tremors, ataxia, pulmonary irritation, asphyxia and, rarely, coma.
"Sudden sniffing death" is seen within minutes to hours of use and is due to ventricular arrhythmias and cardiovascular collapse. Available experimental evidence postulates the following mechanisms: Inhibition of cardiac sodium, calcium, and repolarizing potassium channels hERG and I(Ks) causing reduced conduction velocity and altered refractory period leading to reentry arrythmias or myocardial "sensitiization" to catecholamines resulting in after depolarizations and enhanced automaticity. Treatment should include standard resuscitation measures but refractory arrythmias to defibrillation have been reported and use of amiodarone and beta blockers should be considered.
Bottom Line:
Wound botulism presents as descending paralysis when Clostridium botulinum spores germinate in anaerobic necrotic tissue. There have been hundreds of cases in the last decade, but it is poorly reported outside of California.
Black tar heroin and subcutaneous injection (“skin popping”) carry the highest risk, but other injected drugs and other types of drug use suffice. C botulinum spores are viable unless cooked at or above 85°C for 5 minutes or longer and this is not achieved when cooking drugs.
Early administration of botulism anti-toxin (BAT) not only saves lives but can prevent paralysis and mechanical ventilation. An outbreak of 9 cases between September 2017 and April 2018 cost roughly $2.3 million, in part because patients didn’t present on average until 48 hours after symptom onset and it took an additional 2-4 days before the true cause of their respiratory depression and lethargy were understood. One patient died.
PEARL: talk to your injecting drug users about the symptoms of botulism: muscle weakness, difficulty swallowing, blurred vision, drooping eyelids, slurred speech, loss of facial expression, descending paralysis, and difficulty breathing. Consider botulism early in your patients who inject drugs but who do not respond to naloxone or who exhibit prolonged symptoms. Testing at the health department is performed with mouse antibodies to Botulism Neurotoxin (BoNT) combined with the patient’s serum.
Cyanide poisoning, while uncommon, is frequently fatal. Current antidotes include methemoglobinemia inducers (nitrites), sulfur donators (thiosulfate), and hydroxocobalamin. Each has risks and benefits that must be considered. Three new potential antidotes, including sodium tetrathionate, have recently been evaluated in swine models.
Intramuscular sodium tetrathionate1
Advantages:
Bottom line:
Primary headaches (not secondary to a life-threatening disease) can be challenging to manage. Remember the following pearls:
Things that DO NOT work: IV fluids, 5-HT3 Antagonists (aka Zofran), diphenhydramine (aka Benadryl), opioids
Things that KINDA work: oxygen for all headaches, sphenopalatine ganglion block (4% lido spray)
Things that PREVENT recurrence: dexamethasone for migraine headaches
Children are prone to inflammation and infection of the intervertebral discs
-Mean age 3-5years at presentation.
Lumbar region frequently involved
Although disc biopsy is not necessary for diagnosis, as many as 60% of biopsied discs grow bacteria
-Usually Staphylococcus aureus.
Untreated - may spontaneously resolve or progress to vertebral osteomyelitis or abscess
Chief complaint: Back pain and irritability, often associated with a limp or refusal to crawl or walk.
Fever is absent or low grade.
Physical examination findings are nonspecific and may include a tendency to lie still and percussion tenderness over the involved spine.
Blood culture is generally sterile,
WBC count can be normal early in the disease course
However, the ESR is elevated in >90% of patients.
Plain radiographs are normal at the start of the illness, and generally take 2-3 weeks to demonstrate narrowing of the intervertebral space.
Therefore imaging study of choice is MRI.
Naloxone distribution programs have been expanding to promote the naloxone adminstration by laypersons, usually intranasal (IN) device, to victims of opioid overdose. A recent study analyzed the reports of prehospital naloxone administration reported to a regional poison center.
Opioid toxicity revesal:
However, between 2015 and 2017, the reversal rate decreased (82.1% to 76.4%) while mean administered naloxone dose increased (2.12 mg to 3.63 mg). The cause of this trend is unknown but the dose of commercially available IN naloxone kit increased from 2 mg to 4 mg in 2016.
Bottom line:
Post-Arrest Prophylactic Antibiotics?
Since 2013, the availability of fentanyl has been increasing in the illicit drug supply, especially in heroin supply. Fentanyl and its analogs have been responsible for the dramatic increase in opioid overdose death over the past 5 years.
Two recent cross-sectional studies screened ED patients with opioid use disorder for fentanyl exposure.
Study 1:
Study 2:
Bottom line:
Bottom Line: Underdosing of benzodiazepines in status epilepticus may contribute to treatment failure.
Little people (patients with achondroplasia or "dwarfism") have little lungs. Even though the trunk may appear to be a normal size with small limbs, the vital capacity is actually about 75% the predicted value based on the patient's sitting height. Macrocephaly and a decreased anterior-posterior depth are the cause for this. When you want to mechanically ventilate a little person, you can estimate their height based on a typical person with the same sitting height, but their actual volume will be about 3/4 the tidal volume predicted.
When intubating, remember these patients also have a high risk of basicranial hypoplasia (the foramen magnum may be small and key-hole shaped). These patients will be predisposed to compress the vertebral arteries when you tilt the head back and this itself can cause ischemia of the medulla and pons leading to central apnea.
Stokes DC, Wohl ME, Wise RA, et al. The lungs and airways in Achondroplasia. Do little people have little lungs? CHEST. 1990; 98(1):145-52
Pauli RM. Achondroplasia: A comprehensive review. Orphanet Journal of Rare Diseases. 2019; 14(1):
Acute transverse myelitis (ATM) refers to inflammation of gray and white matter in one or more adjacent spinal cord segments leading to acute/subacute dysfunction of all cord functions (i.e., motor, sensory, and autonomic).
There is a bimodal peak between ages 10-19 years and ages 30-39 years.
Most cases are idiopathic
Some patients may have had a preceding viral infection or autoimmune disorder.
The thoracic cord is most commonly involved.
Onset is characterized by acute/subacute development of neurologic signs and symptoms consistent with motor weakness, sensory changes or autonomic dysfunction.
Pain in the head, neck, and/or back may occur.
Motor and sensory changes occur below the level of the lesion and are more likely to be bilateral.
Motor symptoms include a rapidly progressing paraparesis.
Autonomic dysfunction may include urinary urgency or difficulty voiding, bowel or bladder incontinence, tenesmus, constipation, and sexual dysfunction.
Despite its low incidence, consider in a patient presents with a classic constellation of symptoms,
Rapid identification, and early initiation of treatment predicts the best outcomes
Diagnosis: whole spine MRI with and without gadolinium
Management: goals include reducing cord inflammation (IV glucocorticoids), alleviating symptoms (pain management, bladder decompression), and treating underlying causes (e.g., infections, autoimmune) as appropriate.
Many chemicals and substances - both legal and illegal - can be purchased from an online retailer. A recent study searched Amazon.com to see if any of the "extremely hazardaous substances" identified by Environmental Protection Agency (EPA) were available for purchase.
Amazon.com was searched over 10-month period.
Result:
Bottom line:
Toxic substances are readily available from many online retailers that can potentially cause serious toxicity. Online retailers should consult with experts and governmental agencies to limit the availability of such products.
Some patients with severe pulmonary hypertension receive continuous infusions at home of prostacyclins, such as epoprostanol (flolan). These are generally delivered via a pump that the patient wears, which is attached to an indwelling catheter. As with any indwelling device, they are at risk for infection and other complications, including malfunction.
Interruption of delivery of the medication can result in rapid cardiovascular collapse, sometimes within minutes. In this instance, the medication should be resumed as quickly as possible (by a traditional IV if the catheter is not functional), and the patients should be treated as one would approach a patient with decompensated right heart failure.
I once saw a patient in the ED whose listed chief complaint was "medication refill", but was actually there for dislodgement of her prostacyclin catheter (thankfully she was ok). With more patients receiving devices they are dependent upon (insulin pumps, AICDs, prostacyclin catheters), be wary of chief complaints such as "medication refill" or "device malfunction."
Bottom Line: Interruption of continuous prostacyclin therapy for pulmonary hypertension can be rapidly fatal and should be addressed immediately.
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