Category: Toxicology
Keywords: caustic ingestion; esophageal injury (PubMed Search)
Posted: 4/17/2014 by Hong Kim, MD
(Updated: 11/24/2024)
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Caustic ingestion can potentially cause significant esophageal and/or gastric injury that can lead to significant morbidity, including death.
Endoscopy is often performed:
· To determine the presence of caustic injury.
· To determine the severity of caustic injury (grade: I to III).
Grade | Tissue finding | Sequela |
I | • Erythema or edema of mucosa • No ulceration | No adverse sequela |
IIa | • Submucosal ulceration and exudates • NOT circumferential | No adverse sequela |
IIB | • Submucosal ulceration and exudates • Near or circumferential | Stricture > 70% |
IIII | • Deep ulcers/necrosis • Periesophageal tissue involvement | Acute Perforation and death Chronic Strictures and increased cancer risk |
· Placement of orogastric or nasograstic tube for nutritional support if needed (grade IIb and III)
Evidence for predictor of esophageal injury (frequently cited) comes from mostly studies involving pediatric population and unintentional ingestion:
1. Gaudreault et al. Pediatrics 1983;71:767-770.
o Studied signs/symptoms: nausea, vomiting, dysphagia, refusal to drink, abdominal pain, drooling or oropharyngeal burn
o Presence of symptoms: Grade 0/I lesion: 82%; Grade II: 18%
o Absence of symptoms: Grade 0/I: 88%; Grade II: 12%
2. Crain et al. Am J Dis Child. 1984;138(9):863-865
o Presence of 2 or more (vomiting, drooling and stridor) identified all (n=7) grade II and III lesion.
o Presence of 1 or no symptoms: no grade II/III lesions
o Stridor alone associated with grade II/III lesions (n=2)
o 10% of patients without oropharyngeal burns had grade II/III lesions.
3. Gorman et al. Am J Emerge Med 1990;10(3):189-194.
o Two or more symptoms: vomiting, dysphagia, abdominal pain or oral burns
o Sensitivity: 94%; specificity 49%
o Positive predictive value 43% ; negative predictive value: 96%
o Stridor alone (n=3): grade II or greater lesion
4. Previtera et al. Pediatric Emerg Care 1990;6(3):176-178.
o Esopheal injury in 37.5% of patients without oropharyngeal burn
o Grade II/III injury: 8 patients
Available data suggests that there are no “good” or reliable predictors for esophageal injury.
However, high suspicion for gastrointestinal injury should be considered with GI consultation for endoscopy in the presence of
· Stridor alone
· Two or more sx: vomiting, drooling or stridor (Crain et al)
· Intentional suicide attempt
Category: International EM
Keywords: International, Mental Health, burden of disease (PubMed Search)
Posted: 4/15/2014 by Andrea Tenner, MD
(Updated: 4/16/2014)
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General Information:
Relevance to the US physician:
Bottom Line:
Mental illness is an often-forgotten cause of significant morbidity worldwide. Front-line care delivered by appropriately trained and supervised community-based health workers operating in partnership with emergency physicians, primary care physicians, and mental health specialists is key to address this health crisis.
University of Maryland Section of Global Emergency Health
Author: Terrence Mulligan DO, MPH
Transforming Lives, Enhancing Communities — Innovations in Global Mental Health. February 6, 2014 Patel V. and Saxena S. N Engl J Med 2014; 370:498-501
Category: Critical Care
Posted: 4/15/2014 by Haney Mallemat, MD
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Only 50% of hemodynamically unstable patients will improve their hemodynamics in response to a fluid bolus. However, because excessive fluid administration can lead to organ edema and dysfunction, it is important to give hemodynamically unstable patients only the necessary amount of fluids to improve their hemodynamics.
There are two general categories of assessing a patient's response to volume administration; static and dynamic assessments (see referenced article below):
Static assessment (generally unreliable, but traditionally used):
Physical exam (dry mucus membranes, cool extremities, etc.)
Urine output
Blood pressure
Central venous pressure via central-line
Dynamic assessment (more reliable but more labor intensive)
Pulse Pressure Variation
IVC Distensibility Index
End-expiratory occlusion test
Passive Leg-Raise
There is no simple way to accurately determine the need for a fluid bolus however the integration of the techniques above can help the clinician make better decisions.
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Category: Visual Diagnosis
Posted: 4/14/2014 by Haney Mallemat, MD
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25 year-old female (G1P1) presents with 3 weeks of vaginal bleeding. Her serum beta-HCG is 65,000. Her bedside ultrasound is below; what's the diagnosis?
Answer: Hydatidiform mole (molar pregnancy)
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Category: Cardiology
Keywords: Out of hospital cardiac arrest, OHCA, Prehospital airway management (PubMed Search)
Posted: 4/13/2014 by Ali Farzad, MD
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Optimal out of hospital cardiac arrest (OHCA) airway management strategies remain unclear. In the US, 80% of OHCA patients receive prehospital airway management, most commonly endotracheal intubation (ETI). There is growing enthusiasm for use of supra-glottic airways (SGA) by EMS because of ease of insertion, and the thought that use of SGA reduces interruptions in chest compressions. More recently, studies have suggested improved survival without the insertion of any advanced airway device at all.
A recent secondary analysis of OHCA outcomes in the Cardiac Arrest Registry to Enhance Survival (CARES) compared patients receiving endotracheal intubation (ETI) versus supra-glottic airway (SGA), and also patients receiving [ETI or SGA] with those receiving no advanced airway.
Of 10,691 OHCA, 5591 received ETI, 3110 SGA, and 1929 had no advanced airway. Unadjusted neurologically-intact survival was: ETI 5.4%, SGA 5.2%, no advanced airway 18.6%. Compared with SGA, ETI achieved higher sustained ROSC, survival to hospital admission, hospital survival, and hospital discharge with good neurologic outcome. Moreover, compared with [ETI or SGA], patients who received no advanced airway attained higher survival to hospital admission, hospital survival, and hospital discharge with good neurologic outcome.
Conclusion: In CARES, patients receiving no advanced airway exhibited superior outcomes than those receiving ETI or SGA. When an advanced airway was used, ETI was associated with improved outcomes compared to SGA.
McMullan J, Gerecht R, Bonomo J, et al. Airway management and out-of-hospital cardiac arrest outcome in the CARES registry. Resuscitation. 2014;85(5):617–622. doi:10.1016/j.resuscitation.2014.02.007.
Category: Pediatrics
Posted: 4/11/2014 by Rose Chasm, MD
(Updated: 11/24/2024)
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Category: Toxicology
Keywords: alcohol, gabapentin, dependence (PubMed Search)
Posted: 4/7/2014 by Bryan Hayes, PharmD
(Updated: 4/10/2014)
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In a 12-week treatment course,150 alcohol-dependent patients were randomized to receive placebo, gabapentin 900 mg/day, or gabapentin 1,800 mg/day.
Mason BJ, et al. Gabapentin treatment for alcohol dependence: a randomized clinical trial. JAMA Intern Med 2014;174(1):70-7. [PMID 24190578]
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Category: International EM
Keywords: International, Fever, Hemorrhagic (PubMed Search)
Posted: 4/9/2014 by Andrea Tenner, MD
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General Information:
Clinical Presentation:
Diagnosis:
Treatment:
Bottom Line:
University of Maryland Section of Global Emergency Health
Author: Veronica Pei
The CDC Yellow Book 2014 available at: http://wwwnc.cdc.gov/travel/yellowbook/2014/chapter-3-infectious-diseases-related-to-travel/viral-hemorrhagic-fevers
Category: Critical Care
Keywords: map, sepsis, septic shock, hypertension (PubMed Search)
Posted: 4/7/2014 by Feras Khan, MD
(Updated: 4/8/2014)
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How low should you go? MAP Goals in Septic Shock
Background:
The Trial:
Outcome:
Bottom Line:
Pierre Asfar, M.D., Ph.D. et al. for the SEPSISPAM Investigators
March 18, 2014DOI: 10.1056/NEJMoa1312173
Category: Visual Diagnosis
Posted: 4/7/2014 by Haney Mallemat, MD
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23 year-old female presents complaining of progressive right lower quadrant pain after doing "vigorous" pushups. CT abdomen/pelvis below. What’s the diagnosis? (Hint: it’s not appendicitis)
Answer: Rectus sheath hematoma
Rectus Sheath Hematoma (RSH)
Rectus muscle tear causing damage to the superior or inferior epigastric arteries with subsequent bleeding into the rectus sheath; uncommon cause of abdominal pain but mimics almost any abdominal condition.
May occur spontaneously, but suspect with the following risk factors:
Typically a self-limiting condition, but hypovolemic shock may result from significant hematoma expansion.
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Category: Cardiology
Posted: 3/31/2014 by Semhar Tewelde, MD
(Updated: 4/6/2014)
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Perinatally Infected HIV & Cardiovascular Disease
*Perinatally HIV-infected adolescents are susceptible to aggregate atherosclerotic cardiovascular disease risk, but few studies have quantified risk or developed a scoring system
*A recent study of perinatally HIV-infected adolescents calculated coronary artery and abdominal aorta PDAY (Pathobiological Determinants of Atherosclerosis in Youth) scores using modifiable risk factors: HTN, HLD, smoking, obesity and hyperglycemia
*Significant predictors of a high coronary arteries and abdominal aorta scores include: male sex, Hx AIDS-defining condition, long duration of ritonavir-boosted protease inhibitor, and no prior use of tenofovir
*PDAY scores may be useful in identifying high-risk youth who may benefit from early lifestyle or clinical interventions given their trend of increased aggregate atherosclerotic cardiovascular disease risk factor burden
Patel K, Et al. Aggregate Risk of Cardiovascular Disease Among Adolescents in Perinatally Infected with the Human Immunodeficiency Virus. Circulation Vol 129(11) 18 March 2014, p1204-1212.
Category: Pharmacology & Therapeutics
Keywords: azithromycin, levofloxacin, cardiovascular risk, mortality, dysrhythmia (PubMed Search)
Posted: 3/24/2014 by Bryan Hayes, PharmD
(Updated: 4/5/2014)
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A new study of almost 2 million prescriptions in VA patients compared the risk of cardiovascular death or dysrhythmia in patients receiving azithromcyin, levofloxacin, and amoxicillin.
What they found
Compared with amoxicillin, azithromycin was associated with a significant increase in mortality (HR = 1.48; 95% CI, 1.05-2.09) and dysrhythmia risk (HR = 1.77; 95% CI, 1.20-2.62) on days 1 to 5, but not 6 to 10.
Levofloxacin was associated with an increased risk throughout the 10-day period. Days 1-5 mortality (HR = 2.49, 95% CI, 1.7-3.64) and serious cardiac dysrhythmia (HR = 2.43, 95% CI, 1.56-3.79). Days 6-10 mortality (HR = 1.95, 95% CI, 1.32-2.88) and dysrhythmia (HR = 1.75; 95% CI, 1.09-2.82).
Important limitations
This study did not have a comparator group of patients getting no antibiotics. Previous data suggest patients on any antibiotic (eg, penicillin) have a higher risk of death or dysrhythmia.
The supplemental index shows that patients receiving azithromycin and levofloxacin had more serious infections (eg, PNA, COPD, etc.) which may have put them at higher risk for worse outcome irrespective of antibiotic choice.
What it means
It seems azithromycin and levofloxacin may contribute to a small increase in cardiovascular mortality and dysrhythmia during their use. A previous study found this is more likely in those with existing cardiovascular disease.
Rao GA, et al. Azithromyicin and levofloxacin use and increased risk of cardiac arrhythmia and death. Ann Fam Med 2014;12(2):121-7. [PMID 24615307]
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Category: Pharmacology & Therapeutics
Keywords: naloxone,overdose,heroin,opioid (PubMed Search)
Posted: 4/3/2014 by Ellen Lemkin, MD, PharmD
Click here to contact Ellen Lemkin, MD, PharmD
1. https://www.networkforphl.org/_asset/qz5pvn/network-naloxone-10-4.pdf (Contains each law per state as of March 15, 2014)
2. http://www.usatoday.com/story/news/nation/2014/02/20/stateline-drug-overdose-deaths/5637519/
3. Intranasal Naloxone for Treatment of Opioid Overdose. The Medical Letter. Volume 56 (Issue 1438). March 17, 2014
Category: International EM
Keywords: HIV, global health, infectious disease, rash, puritis (PubMed Search)
Posted: 4/1/2014 by Andrea Tenner, MD
(Updated: 4/2/2014)
Click here to contact Andrea Tenner, MD
You are working in a clinic in Tanzania (or Baltimore, for that matter) when a 24 year old presents with this itchy rash on his feet. What's the diagnosis and what underlying systemic condition does it indicate?
Pruritic Papular Eruptions in HIV
Presentation:
University of Maryland Section for Global Emergency Health
Authors: Van Pham, MD and Colleen Holley, MD
Category: Critical Care
Posted: 4/1/2014 by Mike Winters, MBA, MD
(Updated: 11/24/2024)
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Coagulopathies in Critical Illness - DIC
Hunt B. Bleeding and coagulopathies in critical care. NEJM 2014;370:847-59.
Category: Visual Diagnosis
Posted: 3/31/2014 by Haney Mallemat, MD
(Updated: 4/1/2014)
Click here to contact Haney Mallemat, MD
25 year-old female presents with the following. It seems to have occurred spontaneously and spontaneously resolves during her ED evaluation.
Answer: Raynaud phenomenon
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Category: Orthopedics
Keywords: DeQuervain, Intersection, Syndrome, Tenosynovitis (PubMed Search)
Posted: 3/30/2014 by Michael Bond, MD
(Updated: 11/24/2024)
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DeQuervain and Intersection Syndromes:
Category: Toxicology
Keywords: opioids (PubMed Search)
Posted: 3/27/2014 by Fermin Barrueto
(Updated: 11/24/2024)
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What are characteristics that increase the chance a patient is at risk for opioid-related death? A recent JAMA article begins to tackle this very issues. Baumblatt et al. found the following:
1) Patient with 4 or more prescribers had adjusted odds ratio 6.5 for opioid-related death
2) Patient with 4 or more pharmacies where they get their prescriptions aOR - 6.0
3) Patient with more than 100 mg of morphine equivalents mean per day aOR - 11.2
With the new Maryland Prescription Drug Monitoring program (PDMP) we can start looking at a patient's prescription drug use pattern. The recent JAMA article can help you identify patients at high risk to die an opioid-related death. Use the PDMP and be wary if a patient has more than 4 prescribers or pharmacies or has >100mg of morphine equivalents per day.
High-Risk Use by Patients Prescribed Opioids for Pain and Its Role in Overdose Deaths.
Baumblatt JA, Wiedeman C, Dunn JR, Schaffner W, Paulozzi LJ, Jones TF.
JAMA Intern Med. 2014 Mar 3. doi: 10.1001/jamainternmed.2013.12711. [
Category: International EM
Keywords: multiple myeloma, x-ray, global, neoplasm (PubMed Search)
Posted: 3/26/2014 by Andrea Tenner, MD
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You are evaluating a 40 year old trauma victim and see this on pelvic xray. What are you worried about?
University of Maryland Section for Global Emergency Health
Authors: Colleen Holley, MD and Van Pham, MD
Mulligan, Michael. Multiple Myeloma Imaging. available: http://emedicine.
Category: Critical Care
Keywords: ARDS, Nitric Oxide, acute respiratory failure, mechanical ventilation (PubMed Search)
Posted: 3/23/2014 by John Greenwood, MD
(Updated: 3/26/2014)
Click here to contact John Greenwood, MD
Nitric Oxide appears to have NO role in ARDS
Background: The use of inhaled nitric oxide (iNO) in acute respiratory distress syndrome (ARDS) & severe hypoxemic respiratory failure has been thought to potentially improve oxygenation and clinical outcomes. It is estimated that iNO is used in up to 14% of patients, despite a lack of evidence to show improved outcomes.
Mechanism: Inhaled NO works as a selective pulmonary vasodilator which has been found to improve PaO2/FiO2 by 5-13%, but is costly ($1,500 - $3,000 per day) and increases risk of renal failure in the critically ill.
Study: A recent systematic review analyzed 9 different RCTs (N=1142) and compared mortality between those with severe (PaO2/FiO2 < 100) and less severe (PaO2/FiO2 > 100) ARDS and found that iNO does not reduce mortality in patients with ARDS, regardless of the severity of hypoxemia.
Bottom Line: Inhaled NO is an intriguing option for the treatment of refractory hypoxemic respiratory failure, however there does not appear to be a mortality benefit to justify it's high cost and potentially negative side effects. In the ED, it is important to focus on appropriate lung protective ventilation strategies (TV: 6-8 cc/kg IBW) and maintaining plateau pressures < 30 cm H2O in the initial stages of ARDS to prevent ventilator induced lung injury while awaiting ICU admission.
Reference
Adhikari NK, Dellinger RP, Lundin S, et al. Inhaled nitric oxide does not reduce mortality in patients with acute respiratory distress syndrome regardless of severity: systematic review and meta-analysis. Crit Care Med. 2014;42(2):404-12. [PMID: 24132038]
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