UMEM Educational Pearls - Misc

Category: Misc

Title: Glucometers

Keywords: Glucometer, Accuracy (PubMed Search)

Posted: 11/15/2008 by Michael Bond, MD (Updated: 12/10/2022)
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The glucometer is one of the devices that we quickly reach for in the management of our unresponsive patients, diabetics and in the critically ill.  Recently, I noticed that our Roche Accu-Check has a big sticker on the case stating that results could be affected by therapies that alter the metabolism of galactose, maltose, and xylose.  Since this was a big hole in my fund of knowledge I decided to look up what else affects the accuracy of glucometers.

 Now, Dr. Winters already warned used about the inaccuracy of bedside glucometer readings in the critically ill, but what about the patient that is not septic and/or in shock.

Substances/Drugs that have been reported to affect the accuracy of glucometers are:

  • Levodopa
  • Dopamine
  • Mannitol
  • Acetaminophen
  • Severe lipemia
  • Severe unconguted bilirubin
  • Elevated Uric Acid
  • Maltose (present in immunoglobin products)
  • Patient on peritoneal dialysis secondary to Icodextrin
  • Ascorbic Acid (Vitamin C)

Anemia also results in higher values, and a capillary blood sample can differ from venous blood by as much as 70mg/dL.

Most errors are more significant when dealing with hypoglycemia. 

So the moral of the story is be careful with a bedside glucometer when the reading is low, as the venous blood sample sent to the lab may return even lower.  Error on the side of treating the patient with glucose.

 

 

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Category: Misc

Title: High Altitude Illnesses

Keywords: high altitude illness (PubMed Search)

Posted: 11/1/2008 by Michael Bond, MD (Updated: 12/10/2022)
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High altitude illnesses is typically called Acute mountain sickness (AMS) and is associated with two major complications high altitude pulmonary edema (HAPE) and high altitude cerebral edema (HACE).

Symptoms associated with AMS are headache, fatigue, nausea and vomiting, anorexia and insomia. Cough, Cyanosis, hypoxia, and dyspnea are associated with HAPE.  HACE is associated with progressive neurologic symptoms and can lead to ataxia and coma.

Factors that increase your risk for altitude illnesses are:

  • Rate of ascent
  • Elevation obtained
  • Exertion on arrival to elevation
  • Duration at that altitude
  • Recent URI
  • Previous symptoms of AMS

Category: Misc

Title: Severe Hypothyroidism or Myxedema Coma

Keywords: Hypothyroidism, Myxedema, Treatment (PubMed Search)

Posted: 10/11/2008 by Michael Bond, MD (Updated: 12/10/2022)
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Severe Hypothyroidism or Myxedema Coma

  • Mortality rate has been as high as 80% now 15-20% with aggressive treatment
  • Some common symptoms are:
    • Constipation
    • Depression
    • Lethargy
    • Dry, Brittle hair or Alopecia
    • Weight Gain
    • Cold Intolerance
    • Weight Gain
  • Treatment consists of:
    • Rule out aggravating cause (i.e.: infection)
    • Start IV levothyroxine dosing
      • Initial dose 400-500 mcg (Helps to saturate the thyroid receptors)
      • Daily dose 100 mcg/day
    • Consider starting Dexamethasone or doing a Cortisol stimulation test
      • Patients may also have adrenal insufficiency from primary pituitary failure or may have secondary adrenal suppression due to the severe hypothyroidism.  If dexamethasone is not provided they may develop severe adrenal insufficiency once you kick start their metabolism.

Category: Misc

Title: SVC Syndrome...when to suspect

Keywords: superior vena cava, svc syndrome (PubMed Search)

Posted: 5/20/2008 by Rob Rogers, MD (Updated: 12/10/2022)
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Superior Vana Cava Synrome....when to suspect

 

Two common causes of SVC syndrome include thrombus (secondary to CV catheters) and lung tumors/lymphoma

Consider this diagnosis in patients with a history of cancer and/or who have a central line in place and the complaint of facial swelling. Patients may not look swollen to you.

In addition, make sure to look at their necks and chest wall-presence of asymmetric, prominent veins should prompt consideration for this diagnosis. 

A useful clinical tool is to look at the patient's driver's license (assuming they have one) and compare to their appearance on presentation.

Workup in most cases will involve a CT of the chest.

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Category: Misc

Title: Acute Leukemia

Keywords: Leukemia (PubMed Search)

Posted: 4/28/2008 by Rob Rogers, MD (Updated: 12/10/2022)
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Suspected Acute Leukemia in the ED

 Key ED Interventions for patients with astronomically high WBC counts:

  • Usually talking about WBC counts over 200,000 or so (can be lower in lymphocytic leukemia)
  • Hydrate aggressively
  • Avoid PRBC transfusions as blood products will increase the patient's cytocrit (combination of WBC, platelets, and RBC) and predispose to organ malperfusion. This may lead to WBC (or blast) sludging in the microcirculation and may result in CNS bleeds. 
  • Obviously, call for help immediately! Get a hematologist on the line quickly
  • Assume the patient already has Tumor Lysis Syndrome and administer Allopurinol in a dose of 300 mg orally.
  • Obtain a uric acid level, and if high, give an intravenous infusion of Rasburicase-eliminates preformed uric acid released from leukemia cell lysis. Renal failure results from high uric acid levels. We have this medication at University.
  • The treatment of choice is initiation of definitive chemotherapy....clearly not an option for us in the ED. You can also do leukapheresis (where you take out WBC)....also not an option unless you have a special catheter and a perfusionist/nurse. BUT, you can take off a unit or two of blood (phlebotomy). This will potentially lower the patient's cytocrit. 

Category: Misc

Title: Neutropenic Fever-Pearls and Pitfalls

Keywords: Fever (PubMed Search)

Posted: 3/31/2008 by Rob Rogers, MD (Updated: 12/10/2022)
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Neutropenic Fever

A few pearls about neutropenic fever:

  • Usually occurs a few weeks after chemotherapy (14-21 days)
  • Defined as a fever in the setting of rapidly declining neutrophil count
  • Patients who report fever at home but who are not febrile in the ED should be treated as if they are neutropenic
  • ANC=absolute neutrophil count. Calculated by adding neutrophils and bands together
  • Classification of neutropenia, use the ANC to calculate:  Mild: 1000-1500 cells/mm3, Moderate 500-1000 cells/mm3, and Severe Less than 500 cells/mm3.
  • Mortality rate increases as the ANC drops to below 500 and the duration of neutropenia. These people die of overhwhelming bacterial infections/sepsis.
  • Treatment: #1 Consider the diagnosis, #2 Broad spectrum antibiotic coverage: Imipenem, or Pip/Tazo, or Cefipime. Consider adding Vanc if the patient has a line, looks ill or is hypotensive, or if the patient has been on a fluoroquinolone.

#1 Pitfall:

  • Not initiating broad spectrum antibiotic coverage fast enough. These patients can crash very rapidly.
  • Patients do not have to be febrile in the ED to be diagnosed with this. Their report of fever is enough.
  • Mortality rates drop the faster big gun antibiotics are given. Don't be skimpy and give Unasyn. Use the big bad boys like single agent Pip/Tazo (4.5 grams, not 3.375), Cefipime, etc. Have a low threshold for adding Vancomycin.

IDSA Guidelines on Neutropenic Fever, 2002. New Guidelines coming Summer 2008!

 


Category: Misc

Title: Oncologic Emergencies-SVC Syndrome

Keywords: Oncologic, Emergency, SVC Syndrome (PubMed Search)

Posted: 3/3/2008 by Rob Rogers, MD (Updated: 12/10/2022)
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Clinical Presentation of SVC Syndrome

SVC syndrome (caused either by tumor or thrombosis of the SVC) classically presents with facial swelling, arm swelling, and dilated chest wall veins. The problem in the real world is that often times the manifestaions are a bit more subtle.

Some SVC syndrome pearls:

  • Consider the diagnosis in patients with a generalized complaint of facial swelling or "fullness," particularly if they have an indwelling catheter in place.
  • Consider in patients who complain there face is swollen or red (plethoric) in the morning, or who notice this when their arms are raised (Pemberton's sign)
  • The diagnosis is usually established by CT.
  • Patients with SVC syndrome and the complaint of hoarseness or headache should make you nervous, as these symptoms may indicate laryngeal and cerebral edema.
  • The importance of examining the neck and chest in ED patients cannot be overemphasized. Often the one clue that leads to the diagnosis is prominent and asymetric neck, upper chest, or shoulder veins.
  • Treatment: For tumor related SVC syndrome-head elevation, possibly steroids, radiation therapy (along with biopsy if no cancer diagnosis established); For thrombotic-related SVC syndrome-anticoagulation, Interventional Radiology consult for lytics/stent

 


Category: Misc

Title: Coding and Billing Pearls

Keywords: Coding, Billing, Reimburshment (PubMed Search)

Posted: 12/16/2007 by Michael Bond, MD (Updated: 12/10/2022)
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The insurance companies are always trying to down code our visits so that they can save money, and unless we diagnosis the patients with the appropriate jargon it can cost us a lot of money.  Here are some coding suggestions as written by Sharon Nicks, President and CEO of Nicks & Associates in EP Monthly .

 

Diagnosis
Consider Diagnosising  It this, if the condition fits
Esophagitis
  • Acute Chest Pain
U.R.I.
  • Acute febrille illness with cough
  • Acute tracheobronchitis
Gastroenteritis
  • Acute severe abdominal pain
  • Acute dehydration (volume depletion) secondary to nausea/vomiting
  • Electrolyte imbalance
 Flu/Viral Ilness
  • Acute viremia
  • Acute febrile illness
 Musculoskeletal Pain
  • Acute cervical pain
  • Acute chest wall syndrome
  • Acute strain or pain to a specific (i.e: lumbar) due to a MVA or fall
Otitis Media
  • Acute febrile illness secondary to acute otitis media
  • Otalagia

 

The moral of this pearl is try to use words like Acute, Severe, Sudden, Serious, Distress, Pain, or Fever so that it is clearer to the insurance companies that the patient warranted a visit to a physician (i.e.: an ED) before their PCP could see them in a week.


Category: Misc

Title: Changes to the educational list format

Keywords: administrative, notice, admin, tech (PubMed Search)

Posted: 10/4/2007 by Dan Lemkin, MD, MS (Updated: 12/10/2022)
Click here to contact Dan Lemkin, MD, MS

I have made some improvements to the educational pearl interface. This required recoding several sections to change the text formatting from plain text to html...

Why do you care?

Well, many email clients will block html, or messages that have lots of capitals, decorations, etc...

Our first priority is to get you the information and beat anti-spam auto-filtering. If you notice that you are not getting the educational emails. 
If it still doesn't work, send me an email. If many people are having problems, I will revert to the old system of text entry... But if this works, hopefully it will make the messages easier to read.
Notes to authors
  • Do not use a lot of colors like this post
  • Do not use allcaps, lots of bolding, etc...
thanks
dan

Category: Misc

Title: Medical Management Ureteral Stones

Keywords: Ureteral, stone, tamsulosin, management (PubMed Search)

Posted: 7/21/2007 by Michael Bond, MD (Updated: 12/10/2022)
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Medical Management of Ureteral Stones Tamsulosin (Flomax ) has been shown to help increase the passage of ureteral calculi. According to a metaanalysis compared to patients receiving conservative therapy only, patients receiving conservative therapy plus α -blockers were 44% more likely to spontaneously expel the stones (RR 1.44, 95% CI 1.31 to 1.59, p0.001), and stone expulsion incidence increased significantly (RD 0.28, 95% CI 0.22 to 0.34, p0.001). Mechanism of action: Alpha blockage results in ureteral smooth muscle relaxtion and subsequent inhibition of ureteral spasms and dilatation of the ureteral lumen. Erturhan S. Erbagci A. Yagci F. Celik M. Solakhan M. Sarica K. Comparative evaluation of efficacy of use of tamsulosin and/or tolterodine for medical treatment of distal ureteral stones. [Comparative Study. Journal Article. Randomized Controlled Trial] Urology. 69(4):633-6, 2007 Apr. Parsons JK. Hergan LA. Sakamoto K. Lakin C. Efficacy of alpha-blockers for the treatment of ureteral stones. [Journal Article. Meta-Analysis] Journal of Urology. 177(3):983-7; discussion 987, 2007 Mar.

Category: Misc

Title: Test of new education blog/listserv

Keywords: Listserv, mailing list, test (PubMed Search)

Posted: 7/10/2007 by Dan Lemkin, MD, MS (Emailed: 7/8/2007) (Updated: 12/10/2022)
Click here to contact Dan Lemkin, MD, MS

I am redesigning the way the educational pearls are sent. You will still receive them via email to the education list. This will not change. What will change, is that a record will be available for review on the website in the residency --> pearls section. Currently you can browse the posts as the come in. In the very near future, you will be able to search by keywords and review several pearls at once. This should serve as a really handy review tool. Please bear with me as I test the email system to ensure it comes across ok. thanks dan