Category: Toxicology
Keywords: hf, hydrofluoric acid (PubMed Search)
Posted: 2/27/2014 by Fermin Barrueto
(Updated: 11/24/2024)
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Acid and Alkali burns are all known for their caustic cellular injury to local tissue. Acid burns and specifically hydrofluoric acid has systemic toxicity. HF can be lethal even if there is only a 5-10% total body surface area burn. You can find HF in brick cleaner, glass etching and wheel cleaner. They main metabolic derangement is hypocalcemia which can lead to cardiac dysrrhythmias and death.
Treatment has ranged from IV calcium or even intra-arterial calcium in the affected limb to treat the local severe pain associated with an HF burn. Checking a serum calcium to be sure IV calcium replacement is also necessary.
Remember HF -> severe pain, minimal tissue damage, hypocalcemia, hyokalemia, dysrrhythmias
Category: International EM
Keywords: Vaccine, disaster, international, (PubMed Search)
Posted: 2/26/2014 by Andrea Tenner, MD
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Bottom Line:
University of Maryland Section of Global Emergency Health
Author: Veronica Pei
Use the CDC web module for travelers:
http://wwwnc.cdc.gov/travel/destinations/list
Category: Critical Care
Keywords: INTERACT 2, ATACH II, Intracranial Hemorrhage, Hypertensive Emergency, Hemodynamics (PubMed Search)
Posted: 2/24/2014 by John Greenwood, MD
(Updated: 2/25/2014)
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Intensive BP Control in Spontaneous Intracranial Hemorrhage
Managing the patient with hypertensive emergency in the setting of spontaneous intracerebral hemorrhage (ICH) is often a challenge. Current guidelines from the American Stroke Association are to target an SBP of between 160 - 180 mm Hg with continuous or intermittent IV antihypertensives. Continuous infusions are recommended for patients with an initial SBP > 200 mm Hg.
An emerging concept is that rapid and aggressive BP control (target SBP of 140) may reduce hematoma formation, secondary edema, & improve outcomes.
Recently published, the INTERACT 2 trial (n=2,829) compared intensive BP control (target SBP < 140 within 1 hour) to standard therapy (target SBP < 180) found:
Study flaws: Patients treated with multiple drugs - combinations of urapadil, labetalol, nicardipine, nitrates, hydralazine, and diuretics. Management variability away from protocol seemed high. (Interesting editorial)
A Post-hoc analysis of the INTERACT 2 published just this month suggests that large fluctuations in SBP (>14 mmHg) during the first 24 hours may increase risk of death & major disability at 90 days.
Bottom Line: INTERACT 2 was a large RCT but not a great study (keep on the look out for ATACH II). However, in patients with spontaneous ICH, consider early initiation of an antihypertensive drip (preferably nicardipine) in the ED to reduce blood pressure fluctuations early with a target SBP of 140 mmHg.
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Category: Visual Diagnosis
Posted: 2/24/2014 by Haney Mallemat, MD
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50 year-old with facial weakness and dysarthria. What's the diagnosis?
Stroke secondary to neurocysticercosis
Neurocysticercosis
Neurocysticercosis occurs secondary to ingestion of eggs from the Taenia solium tapeworm; ingestion typically occurs from ingestion of contaminated food.
Most patients are asymptomatic but symptoms of neurocysticercosis may include
Diagnosis is made via imaging such as CT scan; findings may vary depending on what stage of life the parasite is in (e.g., larvae); lumbar puncture should also be performed if the diagnosis is suspected.
Management should be symptomatic (e.g., seizures receive anticonvulsants) as well as eradication of the active parasites using steroids followed by albendazole (anti-parasitic drug)
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Category: Cardiology
Keywords: ACS, Stress Test (PubMed Search)
Posted: 2/23/2014 by Ali Farzad, MD
(Updated: 3/23/2014)
Click here to contact Ali Farzad, MD
1. Banerjee A, Newman DR, Van den Bruel A, Heneghan C. Diagnostic accuracy of exercise stress testing for coronary artery disease: a systematic review and meta-analysis of prospective studies. International Journal of Clinical Practice. 2012;66(5):477–492.
2. Walker J, Galuska M, Vega D. Coronary disease in emergency department chest pain patients with recent negative stress testing. West J Emerg Med. 2010;11(4):384–388.
3. Nerenberg RH, Shofer FS, Robey JL, Brown AM, Hollander JE. Impact of a negative prior stress test on emergency physician disposition decision in ED patients with chest pain syndromes. The American journal of emergency medicine. 2007;25(1):39–44.
Category: Orthopedics
Keywords: MRSA, arthocentesis (PubMed Search)
Posted: 2/22/2014 by Brian Corwell, MD
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The clinical examination is often unreliable in ruling out septic arthritis in the ED.
Diagnostic arthrocentesis is often performed.
Traditional teaching involved very high WBC count thresholds as part of diagnosis.
In one 2009 study, synovial leukocyte counts in cases of MRSA were often less than 25,000 cells/uL
Have a low threshold for empiric antibioitics even in the face of low WBC counts (and incredulous consultants)
How Common is MRSA in Adult Septic Arthritis? Frazee et al., 2009
Category: Pediatrics
Keywords: Passive leg raise, hypotension (PubMed Search)
Posted: 2/21/2014 by Jenny Guyther, MD
(Updated: 11/24/2024)
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Passive leg raise (PLR) has been studied in adults as a bedside tool to predict volume responsiveness (see previous pearls from 5/7/13 and 6/17/2008). Can this be applied to children?
A single center prospective study looked at 40 intensive care patients ranging in age from 1 month to 12.5 years. They used a noninvasive monitoring system that could measure heart rate, stroke volume and cardiac output. These parameters were measured at a baseline, after PLR, after another baseline and after a 10 ml/kg bolus.
Overall, changes in the cardiac index varied with PLR. However, there was a statistically significant correlation in children over 5 years showing an increase in cardiac index with PLR and with a fluid bolus.
Bottom line: In children older then 5 years, PLR can be a quick bedside tool to assess for fluid responsiveness, especially if worried about fluid overload and in an under served area.
Lu et al. The Passive Leg Raise Test to Predict Fluid Responsiveness in Children - Preliminary Observations. Indian J Pediatr. Dec 2013. (epub ahead of print).
Category: International EM
Keywords: Cirrhosis, Hepatitis, International (PubMed Search)
Posted: 2/19/2014 by Andrea Tenner, MD
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General Information:
Bottom Line:
Tenofovir has already become standard therapy for HIV (contained in Truvada and Atripla). This HBV study shows promise that this drug can not only decrease progression of disease but also reverse the cirrhosis associated with long-term infection. Given the prevalence of chronic HBV, larger scale role-out of this drug could markedly change the epidemiologic landscape of morbidity and mortality due to hepatitis B.
University of Maryland Section of Global Emergency Health
Author: Emilie J.B. Calvello
References: Marcellin P et al. Regression of cirrhosis during treatment with tenofovir disoproxil fumarate for chronic hepatitis B: A 5-year open-label follow-up study. Lancet 2012 Dec 10.
Category: Critical Care
Posted: 2/18/2014 by Haney Mallemat, MD
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Zimmerman, J.Cocaine intoxication. Crit Care Clinics 2012 Oct;28(4):517-26
Category: Visual Diagnosis
Posted: 2/17/2014 by Haney Mallemat, MD
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44 year-old construction worker fell off a ladder and presents with elbow pain. What's the diagnosis and what is the most commonly associated nerve injury?
Olecranon fracture; the ulnar nerve is most commonly injured
Pearls for Olecranon Fracture
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Category: Cardiology
Posted: 2/16/2014 by Semhar Tewelde, MD
(Updated: 11/24/2024)
Click here to contact Semhar Tewelde, MD
Early Atherosclerosis Detection
50 middle-aged asymptomatic subjects free of vascular disease underwent carotid ultrasound (CUS) for risk stratification were also invited to undergo coronary computed tomography angiography (CCTA) or coronary artery calcium score (CAC) to identify which of the 3 imaging modalities was best at identification of early atherosclerosis
Atherosclerosis was observed in 28%, 78%, and 90% of subjects using CAC, CCTA, and CUS, respectively
36 patients with a CAC score = 0, 69% and 86% had atherosclerosis on CCTA and CUS, respectively
Concordance between modalities was highly variable
CUS and CCTA detection of plaque were significantly more sensitive than CAC
Considering the prevalence of subclinical disease on CUS and CCTA, the threshold at which to treat warrants further research
Schroeder B, Francis G, et al. Early Atherosclerosis Detection in Asymptomatic Patients: A Comparison of Carotid Ultrasound, Coronary Artery Calcium Score, and Coronary Computed Tomography Angiography. Canadian Journal of Cardiology, 2013-12-01, Volume 29, Issue 12, Pages 1687-1694
Category: Pediatrics
Keywords: metabolic, inborn errors of metabolism, hyperammonemia (PubMed Search)
Posted: 2/14/2014 by Danielle Devereaux, MD
Click here to contact Danielle Devereaux, MD
Inborn errors of metabolism (IEM) are rare, each typically affecting 1 in 5000 to 1 in 100,000 children, BUT collectively these disorders are more common because there are so many. If you are lucky…when they present to the ED they come with a letter from Dr. Greene (our world renowned metabolic geneticist) detailing exactly what to do. The rest of the time…you are on your own. Think about IEM in any neonate or child with history of feeding difficulties, failure to thrive, recurrent vomiting, unexplained altered mental status and/or acidosis. Pay particular attention to feeding difficulties that appear with changes in diet: switch from soy to cow’s milk formula (galactose), addition of juice or fruit or certain soy formulas (fructose), switch from breast milk to formula or foods (increased protein load), and longer fasting periods from sleeping or illness.
For this pearl, we will focus on primary hyperammonemia from an enzymatic block in ammonia metabolism within the urea cycle. It is important to remember that secondary hyperammonemia can result from metabolic defects such as organic acid disorders, fatty acid oxidation disorders, drugs that interfere with urea cycle, or severe liver disease. Amino acids liberated from excess protein breakdown (stress of newborn period, infection, injury, dehydration, surgery, or increased intake) release nitrogen which circulates as ammonia. Ammonia is then converted to urea via the urea cycle and excreted in the urine. With urea cycle defects (UCD) there is an enzymatic block in the cycle that results in accumulation of ammonia which has toxic effects on the CNS especially cerebral edema. The most common UCD is ornithine transcarbamylase deficiency followed by argininosuccinic academia, and citrullinemia.
Clinical presentation includes poor feeding, lethargy, tachypnea, hypothermia, irritability, vomiting, ataxia, seizures, hepatomegaly, and coma. Hyperammonemic crises in neonates mimic sepsis! If you think about an IEM in your differential, send plasma ammonia (1.5 mL sodium-heparin tube on ice STAT), plasma amino acids, and urine organic acids. Other helpful labs include blood gas, CMP, urinalysis (looking at ketones), lactate, plasma acylcarnitines, and newborn screen if not already sent. Plasma ammonia is a direct index of CNS toxicity and important to follow for acute management. Serum level > 150 in sick neonate or > 100 in sick infant/child is concerning for IEM. The presence of hyperammonemia and respiratory alkalosis suggest urea cycle defect. The presence of metabolic acidosis and hyperammonemia suggests organic acid disorder.
Immediate treatment of hyperammonemia is critical to prevent neurologic damage. Cognitive outcome is inversely related to the number of days of neonatal coma caused by the cerebral edema.
1. Stop all protein intake! You need to stop catabolism.
2. Start D10 at 1.5 times maintenance rate with GIR at least 6-8. Start intralipids 1-3g/kg/day when able (typically in the ICU after central line placed).
3. Give ammonia scavenger medications sodium benzoate and sodium phenylacetate. These are available commercially as Ammonul.
a. 0-20kg: 2.5mL/kg IV bolus over 90 min followed by same dose as 24 hr infusion
b. >20kg: 55 mL/m2 IV bolus over 90 min followed by same dose as 24 hr infusion
4. HEMODIALYSIS! Dialysis is the most effective way to remove ammonia and should be done when level > 300. The decision to hemodialyze is crucial in preventing irreversible CNS damage; when in doubt in the face of elevated ammonia, HEMODIALYZE!
Category: Toxicology
Keywords: bupropion, citalopram, seizure, drug-induced, children, teenager (PubMed Search)
Posted: 2/3/2014 by Bryan Hayes, PharmD
(Updated: 2/13/2014)
Click here to contact Bryan Hayes, PharmD
Seizures can be the presenting manifestation of acute poisoning in children.
A 3-year data set from the Toxicology Investigators Consortium (ToxIC) Case Registry identified 142 cases of drug-induced seizures in children < 18 years old. 75% were teenagers.
Antidepressants were most commonly associated with causing seizures, especially bupropion and citalopram. Diphenhydramine was also a commonly identified cause.
The authors conclude that clinicians managing teenagers presenting with seizures should have a high index of suspicion for intentional ingestion of antidepressants.
Finkelstein Y, et al. Drug-induced seizures in children and adolescsents presenting for emergency care: current and emerging trends. Clin Toxicol 2013;51(8):761-6. [PMID 23957582]
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Category: International EM
Keywords: boarding, ACEP, america, american, global (PubMed Search)
Posted: 2/12/2014 by Andrea Tenner, MD
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Bottom line
ED crowding remains a critical problem in the US and globally. It is frequently driven by the “boarding” of admitted patients. Improved patient flow is needed to be able to take care of patients presenting with acute care needs.
University of Maryland Section of Global Emergency Health
Author: Jon Mark Hirshon, MD, MPH, PhD
www.emreportcard.org; America's Emergency Care Environment, A State-by-State Report Card: 2014 Edition. Report Card Task Force Members; ACEP Staff. Ann Emerg Med. 2014. Feb;63(2):100-243
Category: Critical Care
Keywords: accidental hypothermia, rewarming, ecmo, artic sun (PubMed Search)
Posted: 2/11/2014 by Feras Khan, MD
(Updated: 11/24/2024)
Click here to contact Feras Khan, MD
A 50yo man found dow in the snow was brought into our ER last week in cardiac arrest with a bladder temperature of 21° C. Let’s warm him up!
We were able to get ROSC with CPR and ACLS and then used Artic Sun to re-warm successfully.
Other tips/tricks:
Category: Visual Diagnosis
Posted: 2/9/2014 by Haney Mallemat, MD
(Updated: 2/10/2014)
Click here to contact Haney Mallemat, MD
25 year-old male presents after falling off his bicycle. He complains of pain in his right-hand (he is right-hand dominant). What's the diagnosis?
Answer: Gamekeeper's thumb or Skier's thumb
Injury to the ulnar collateral ligament (UCL) secondary
Called “Gamekeeper Thumb” because injury was originally described in gamekeepers who job was to break the necks of captured game (or animals). The act of breaking necks led to a repetitive stress and injury secondary to the valgus forces on the thumb.
UCL can become torn or avulsed from the insertion on the proximal phalanx; the UCL is an important stabilizer of the thumb; improper management can lead to future disability.
Treatment is with a short-arm thumb-spica cast and follow up with a hand surgeon to determine whether management will be conservative or operative.
Chuter GS, Muwanga CL, Irwin LR (June 2009). "Ulnar collateral ligament injuries of the thumb: 10 years of surgical experience". Injury 40 (6): 652–6 Wheeless' Textbook of Orthopaedics Online: Surgical treatment of acute gamekeeper's thumb
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Category: Cardiology
Keywords: ECG, STEMI, aVL (PubMed Search)
Posted: 2/9/2014 by Ali Farzad, MD
(Updated: 3/23/2014)
Click here to contact Ali Farzad, MD
The importance of new ST-segment depressions (STD) and/or T wave inversions (TWI) in lead aVL have not been emphasized or well recognized across specialties. Computer-assisted ECG readings typically report these findings as normal or nonspecific.
There is growing evidence that changes in lead aVL are abnormal, and that paying attention to that lead can be clinically useful. Reciprocal changes presenting as STD or TWI in lead aVL may be indicative of a significant coronary artery lesion and can sometimes be the only ECG manifestation of acute MI.
STD in lead aVL is considered a sensitive marker for early inferior STEMI, and has been shown to help differentiate STEMI from pericarditis. Another recent retrospective study suggests that TWI in aVL might be associated with significant LAD lesions.
Bottom Line: Paying close attention to subtle changes and abnormalities in lead aVL may help in early identification and initiation of therapy for patients who are having an acute MI.
Hassen GW, Costea A, Smith T, et al. The Neglected Lead on Electrocardiogram: T Wave Inversion in Lead aVL, Nonspecific Finding or a Sign for Left Anterior Descending Artery Lesion?. Journal of Emergency Medicine. 2014;46(2):165–170.
Category: Orthopedics
Keywords: Overtraining syndrome, exercise (PubMed Search)
Posted: 2/8/2014 by Brian Corwell, MD
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Overtraining syndrome
A maladaptive response to excessive exercise without adequate functional rest
-Results in disturbances of multiple body systems (neurologic, endocrinologic, immunologic and psychologic).
- May be caused by systemic inflammation and resultant neurohormonal changes
- Multiple hypotheses exist
-Symptoms
Parasympathetic alterations: fatigue, depression, bradycardia
Sympathetic alterations: insomnia, irritability, agitation, tachycardia, hypertension, restlessness
Other: anorexia, weight loss, poor concentration, anxiety
Usual presentation is prolonged underperformance despite adequate rest and recovery (weeks to months).
Category: Pediatrics
Posted: 2/7/2014 by Rose Chasm, MD
(Updated: 11/24/2024)
Click here to contact Rose Chasm, MD
Cruz AT, Perry AM, Williams EA, et al. Implementaion of Goal-Directed Therapy for Children With Suspected Sepsis in the Emergency Department. Pediatrics 2011;127;e758.
Category: Toxicology
Keywords: ondansetron, dystonia (PubMed Search)
Posted: 2/6/2014 by Fermin Barrueto
(Updated: 11/24/2024)
Click here to contact Fermin Barrueto
Ondansetron (Zofran) is a great anti-emetic that, since it has gone generic, is also inexpensive. High dose ondansetron has been reported to cause QT prolongation and that practice is largerly discontinued now in the oncology world. Another uncommon adverse drug reaction may be dystonia. Though we think of ondansetron as a 5-HT3 blocker and should not cause the dystonic reaction like we see in metoclopramide, there are case reports of this reaction occurring.