UMEM Educational Pearls

Question

28 year-old cachectic female presents in respiratory distress and is immediately intubated on arrival to Emergency Department. What's the diagnosis and what are some potential etiologies?

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Title: Diagnosis of STEMI in LBBB

Category: Cardiology

Keywords: AMI, LBBB, Sgarbossa criteria (PubMed Search)

Posted: 11/9/2013 by Ali Farzad, MD (Updated: 3/10/2014)
Click here to contact Ali Farzad, MD

Diagnosis of STEMI in patients with LBBB can be challenging. Guidelines that previously recommended emergent reperfusion for these patients have been reconsidered to avoid inappropriate cath lab activation and fibrinolytic therapy.

The 2013 ACC/AHA STEMI guidelines no longer consider new or presumably new LBBB a STEMI equivalent. This dramatic change may prevent inappropriate therapy for some, but fail to help identify patients with LBBB who are having STEMI's. Delayed reperfusion in this population could be fatal and is estimated to affect 5,000-10,000 patients per year in the US alone.

The Sgarbossa ECG criteria are the most validated tool to aid in the diagnosis of STEMI in the presence of LBBB. A Sgarbossa score of ≥ 3 has high specificity (>98%) and positive predictive value for acute MI and angiography-confirmed coronary occlusion. The following algorithm has been recently proposed to identify the high-risk population in which reperfusion therapy would be denied by the 2013 STEMI guidelines.

Watch this video to review Sgarbossa criteria and the modified Sgarbossa rule.

 

Want more emergency cardiology pearls? Follow me @alifarzadmd

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Title: Cauda Equina

Category: Orthopedics

Keywords: back pain, cauda equina (PubMed Search)

Posted: 11/4/2013 by Brian Corwell, MD (Updated: 11/9/2013)
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Cauda equina syndrome results from compression of multiple lumbar and sacral nerve roots

Causes: Central disc herniation, spinal epidural abscess, malignancy, trauma, hematoma.

Consider this entity in those with back pain and radiculopathy at multiple spinal levels

Urinary retention occurs in >90% of patients

Saddle anesthesia occurs in 75%

Decreased rectal sphincter tone occurs in 60 to 80%

A post void residual volume <100 mL makes this entity very unlikely



Title: Cephalosporin Side Chains and Allergies

Category: Pharmacology & Therapeutics

Keywords: Cephalosporin,penicillin,anaphylaxis,urticaria,cross sensitivity (PubMed Search)

Posted: 11/7/2013 by Ellen Lemkin, MD, PharmD (Updated: 11/24/2024)
Click here to contact Ellen Lemkin, MD, PharmD

When patients with severe allergies to penicillin (urticarial, bronchospasm, anaphylaxis, angioedema) are excluded, the cross reactivity to cephalosporins is very low (approximately 0.1%)

The reaction is related to structures in the side chain, not the cyclical structure as thought in the past.

There are several cephalosporins with IDENTICAL side chains that should not be given to patients with allergies to specific penicillins, namely:

  • Penicillin:   do not give cefoxitin
  • Ampicillin:   do not give cefaclor or cephalexin
  • Amoxicillin: do not give cefadroxil or cefprozil

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Title: Isolation criteria for MERS-CoV

Category: International EM

Keywords: MERS-CoV, Viral Illness, Respiratory (PubMed Search)

Posted: 11/6/2013 by Andrea Tenner, MD
Click here to contact Andrea Tenner, MD

Case Presentation:

A 56y/o man with diabetes presents with fever, cough, and diarrhea x 2 days. 

V/S: T:38.7 BP:165/88 P: 105 R:24 O2 sat:91% on room air

CXR: left lower lobe infiltrate. 

On further history you learn he has just returned from visiting family in Saudi Arabia 7 days ago.  While there, he visited a cousin that was ill. 

 

Clinical Question:

Should this patient be isolated for Middle Eastern Respiratory Syndrome – Corona Virus (MERS-CoV)?

 

Answer:

Yes, there are 150 cases to date and 64 have died.  None confirmed in the US yet but 6 confirmed in Europe.

 

Patients who should be isolated in an airborne iso room with N95 mask use (similar to TB) are:

Patients with fever + pneumonia/ARDS AND one of the following:

  • Travel to the Arabian Peninsula within 14 days of symptom onset
  • Close contact with a person with fever and respiratory illness within 14 days of travel to the Arabian Peninsula
  • Member of a cluster of patients with severe ARI being evaluated for MERS-CoV

 

Bottom Line:

In patients with febrile respiratory illness requiring hospitalization and recent travel to the Arabian Peninsula: isolate for MERS-CoV and contact the health department.

 

University of Maryland Section of Global Emergency Health

Author: Jenny Reifel Saltzberg

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Title: Ineffective Triggering - The Most Common Vent Dyssynchrony

Category: Critical Care

Keywords: Mechanical ventilation, Critical Care, Intubation (PubMed Search)

Posted: 10/29/2013 by John Greenwood, MD (Updated: 11/5/2013)
Click here to contact John Greenwood, MD

 

Ineffective triggering is the most common type of ventilator dyssynchrony.  The differential diagnosis includes:

  • Auto peep (the most common cause) 
  • Neuromuscular weakness 
  • Improper ventilator settings

Auto peep is the most common cause of ineffective triggering and will often occur as a patient cannot create enough inspiratory force to overcome their own intrinsic peep (PEEPi).  Patients who are severely tachypnic or those with obstructive lung disease are at high risk for auto peep (not enough time to exhale).

Ineffective triggering can also occur if the patient cannot create enough of a negative inspiratory force to trigger the vent to deliver a positive pressure breath. Prolonged period of mechanical ventilation, over sedation, high cervical spine injuries, or diaphragmatic weakness are common causes.

Lastly, improper trigger sensitivities may make it difficulty for the ventilator to sense when the patient is attempting to take a spontaneous breath.  

For an example of a patient with ineffective triggering, check out: http://marylandccproject.org/2013/10/28/vent-problems1/

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Question

This week's visual pearl reviews the structures of the heart when being viewed in a parasternal long-axis view. What do the labels correspond to in the clip below (note: "E" and "F" are valves) and do you see any obvious abnormalities?  

 

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Secondary Prevention in AMI

Just as aspirin is pivotal in the treatment of acute coronary syndrome, medications such as beta-blocker, statins, and angiotensin-converting enzyme inhibitors have been proven to be essential in secondary prevention of AMI.

Patients after AMI are typically discharged on appropriate secondary prevention medications; however the prescribed doses are often far below the proven efficacy based on clinical trials.

A review of 6,748 patients from 31 hospitals enrolled in 2 U.S. registries (2003 to 2008) illustrated that only 1 in 3 patients were prescribed these medications at goal doses.

Of patients not discharged on goal doses, up-titration during follow-up occurred infrequently ~25%.

Optimal medication dosing and appropriate titration is integral to prevention of further morbidity and mortality.

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Title: Nail in the NAC Coffin for Prevention of Contrast-Induced Nephropathy

Category: Pharmacology & Therapeutics

Keywords: contrast-induced nephropathy, n-acetylcysteine, NAC (PubMed Search)

Posted: 10/31/2013 by Bryan Hayes, PharmD (Updated: 11/2/2013)
Click here to contact Bryan Hayes, PharmD

A recent meta-analysis has called into question whether contrast-induced AKI even occurs after an IV dye load for radiologic imaging. [1] This conclusion is most certainly up for debate.

Irrespective of that conclusion, prevention of contrast-induced nephropathy is still important. Is there any benefit to using N-acetylcysteine over normal saline in the ED? Probably not according to a new study. [2]

  • The primary outcome was contrast-induced nephropathy, defined as an increase in creatinine level of 25% or 0.5 mg/dL, measured 48 to 72 hours after CT.
  • The authors found no reduction in contrast-induced nephropathy in patients who received NAC vs normal saline (about 7% in each group).
  • The important finding is that the contrast-induced nephropathy rate in patients receiving less than 1 L IV fluids in the ED was 13% compared to 3% for more than 1 L.

Conclusions

  1. Contrast-induced AKI does happen after emergency CT.
  2. NAC does not provide additional benefit over saline alone.
  3. Giving more than 1 L of normal saline markedly reduces the risk.

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Title: The cough is keeping them awake all night!

Category: Pediatrics

Keywords: cough, upper respiratory infection, children, honey (PubMed Search)

Posted: 11/1/2013 by Danielle Devereaux, MD
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How many times have you been frustrated in the peds ED when you have a child with a URI that has a significant night time cough and you feel like you have nothing to offer them for symptom control?  The parent is frustrated because the child is not sleeping which means they are not sleeping and they are looking at you for help.  We all know that OTC cough and cold medications are not helpful and may be harmful in children <2 yrs old and should be used with caution in children <6 yrs old.  So what can you do?  You can recommend a course of HONEY at night.  Of course this does not apply to children < 1 yr who are at increased risk of botulism.  A recent double-blind placebo-controlled trial published in Pediatrics in 2012 demonstrated reduced night time cough and subjective improved sleep quality in children age 1-5 who were given honey compared to placebo.  This study supports previous less rigorous publications that found honey was an effective remedy on cough in children.  Mechanism for honey's beneficial effect on cough is unknown but possibly related to close anatomic relationship between sensory nerve fibers that initiate cough and gustatory nerve fibers that taste sweetness.  Of note, a recently published survey in Pediatric Emergency Care revealed that 2/3 of parents were unaware of the FDA guidelines regarding OTC cough and cold remedies in children!  After you recommend HONEY for night time cough, take an extra minute and educate your parents about the potential dangers of cough and cold medicines in small children!

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Title: Halloween Candy - Which one is toxic?

Category: Toxicology

Keywords: glycyrrhizic acid, licorice (PubMed Search)

Posted: 10/31/2013 by Fermin Barrueto (Updated: 11/24/2024)
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You have a treat bag full of candy, which one can cause hypertension, hyopkalemia, metabolic alkalosis, rhabdomyolysis, low renin activity, thrombocytopenia and hypoaldosteronism. (scroll down for answer)

 

 

 

 

 

 

 

Licorice syrup or licorice extract contains glycyrrhizic acid which has a mineralcorticoid-like effect and can cause of all of the effects. Don't worry, Twizzlers and other usual licorice candies do not have true licorice extract in them. It is found in herbal remedies and some "natural" candies and licorice flavored cigars. Don't pick the licorice !

 

 



Title: The FASH exam

Category: International EM

Keywords: international, EPTB, extrapulmonary, tuberculosis, ultrasound (PubMed Search)

Posted: 10/30/2013 by Andrea Tenner, MD
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Case Presentation: 28 year old woman from South Africa presents with 5 days of body weakness, nausea, vomiting and cough. BP 86/38, HR 142, RR 36, Temp 101.4 (oral) Sats 96% on RA. PMH: HIV+ last CD4=33, on HAART, history of pulmonary TB which was treated 2 years ago.

Clinical Question: The CT scanner, Xray and labs are down. What work-up can you do to best manage this patient?

Answer: The FASH Exam (Focused Assessment with Sonography for TB-HIV)

Technique: 6 probe positions--Similar to the FAST exam but with additional evaluation of the liver, the aorta, the spleen, as well as evaluation for pleural effusions over the diaphragm.

Evaluate for extrapulmonary TB (EPTB):

-Pericardial/Pleural effusion and ascites

-Periportal/para-aortic lymph nodes

-Focal liver and spleen lesions

(Go to http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3554543/ to view images of probe position.)

Bottom Line: The FASH exam can be taught to physicians with limited to no ultrasound experience. If there is concern for EPTB in an undifferentiated hypotensive patient, the FASH exam can performed in the emergency setting and treatment can be started.

University of Maryland Section of Global Emergency Health

Author: Laura Diegelmann, MD RDMS

 

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The pregnant patient normally has increased cardiac output and minute ventilation by the third trimester. Despite this increase, however, these patients have little cardiopulmonary reserve should they become critically-ill.

Remember the mnemonic T.O.L.D.D. for simple tips that should be done for the pregnant patient who presents critically-ill or with the potential for critical illness: 

  • Tilt: The supine-hypotension syndrome occurs after the 20th week of pregnancy as the gravid uterus compresses the IVC and aorta, reducing cardiac output by up to 30%. Placing a 30-degree right hip-wedge under the patient will relieve this obstruction.
  • Oxygen: the growing uterus pushes up on the base of the lungs reducing the functional residual capacity meaning there is less oxygen reserve and rapid oxygen desaturations. Supplemental oxygen may increase the patient's reserve.
  • Lines: The circulatory system reserve is reduced, so early and large bore venous access is important. Remember that lines should be placed above the diaphragm because the enlarging uterus compresses pelvic veins, reducing venous return to the heart.
  • Dates: Rapidly determine the gestational age of the fetus as 24 weeks is a critical date to remember (e.g., increased risk of supine-hypotension syndrome, fetal viability, etc.)
  • Delivery: Call labor and delivery early on, not only for the consultation, but also for the fetal monitoring that this service provides. 

 

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Question

15 year-old right-hand dominant male received a direct blow to the right arm with a hockey stick. What’s the diagnosis?

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Title: Marked First Degree AV Block

Category: Cardiology

Keywords: AV Block (PubMed Search)

Posted: 10/27/2013 by Ali Farzad, MD (Updated: 3/10/2014)
Click here to contact Ali Farzad, MD

First-degree atrioventricular (AV) block is defined as an abnormally prolonged PR-interval >200ms. Although traditionally considered to be a benign clinical entity, not all first degree AV blocks are treated the same.  

Markedly prolonged PR-intervals (PR >300ms) can cause symptoms and hemodynamic compromise due to inadequate timing of atrial and ventricular contractions. Consider the following ECG from a 32 YOF with intermittent episodes of syncope and dizziness…

There is marked first degree AV block (PR=434 ms). When the PR-interval gets too long, AV dyssynchrony compromises ventricular filling and decreases cardiac output, similar to the so-called pacemaker syndrome.

Current ACC/AHA guidelines state that permanent pacemaker implantation is reasonable for marked first degree AV block with hemodynamic compromise or symptoms similar to those of pacemaker syndrome. (Class IIa, Level of Evidence B). The guidelines caution that pacemakers are not indicated in asymptomatic patients with isolated first degree AV block.

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Title: Lateral hip pain

Category: Orthopedics

Keywords: gluteus, trendelenberg test, hip pain (PubMed Search)

Posted: 10/26/2013 by Brian Corwell, MD (Updated: 11/24/2024)
Click here to contact Brian Corwell, MD

 Lateral hip pain

 

 

 Findings of weakness and/or pain while testing hip abduction may point to gluteus medius muscle dysfunction with associated with greater trochanteric pain syndrome.

 

The Trendelenburg test may help. The patient stands on the affected leg. A negative test result occurs when the pelvis rises on the opposite side. A positive test result occurs when the pelvis on the opposite side drops and indicates a weak or painful gluteus medius muscle.

 

http://www.youtube.com/watch?v=TY-G4ErruUA
 



Title: Follow Up on Phenergan IV - Why Not IM

Category: Toxicology

Keywords: promethazine (PubMed Search)

Posted: 10/25/2013 by Fermin Barrueto (Updated: 11/24/2024)
Click here to contact Fermin Barrueto

Yesterday's pearl generated several questions that I thought were worth answering briefly:

1) Why give it IM? Absorption rate is faster than SQ infiltration though theoretically could still cause necrosis

2) Is it only infilitration? Gangrene has occurred with inadvertent intra-arterial injection, SQ infiltration and even regular IV administration

3) Mechanism? Appears to be the drug and not diluent, diluting down the concentration as well as decreasing dose appears to help if you are going to give it IV

Here is a website if you wish to read more details:

https://www.ismp.org/newsletters/acutecare/articles/20060810.asp

 



Title: Intravenous Phenergan

Category: Toxicology

Keywords: Promethazine (PubMed Search)

Posted: 10/24/2013 by Fermin Barrueto (Updated: 11/24/2024)
Click here to contact Fermin Barrueto

If you are still using IV Phenergan, you need to be aware of the necrotic effect that occurs if it infiltrates. EDs have even removed it from their drug dispensing machines. It appears to be the drug and not the diluent. Mechanism is not completely understood. Below is a picture the plaintiff attorney will use about this well know adverse effect. If so many alternatives for IV antiemetic it is wise to reconsider IV phenergan.

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Title: Pediatric Care in Disasters

Category: International EM

Keywords: Pediatrics, Disaster (PubMed Search)

Posted: 10/23/2013 by Andrea Tenner, MD
Click here to contact Andrea Tenner, MD

General Information:

  • 50% of victims in man-made and natural disasters are children.
  • In low and middle income countries (where 95% of disasters occur), children are particularly vulnerable.
  • Early responders must be well versed in caring for pediatric diarrheal disease, acute respiratory tract infections, measles, malaria, severe bacterial infections, malnutrition, micronutrient deficiencies, injuries, burns and poisonings with few resources.
  • Pediatric specific triage systems have been developed to aid in resource allocation during mass casualty responses.
  • Pediatric patients are singularly vulnerably to exploitation, abuse and trafficking during disaster, particularly when they are separated from their families.

 

Area of the world affected:

  • All

 

Bottom Line:

  • Many US based emergency medicine physicians are keen to respond to international disasters.  A clear understanding about the particular risks to children during disaster response are critical in order to care for the most vulnerable of disaster victims.

 

 

University of Maryland Section of Global Emergency Health

Author: Emilie J.B. Calvello, MD, MPH

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Title: TRALI- Transfusion related lung injury

Category: Critical Care

Keywords: TRALI, TACO, Transfusion, acute lung injury (PubMed Search)

Posted: 10/22/2013 by Feras Khan, MD
Click here to contact Feras Khan, MD

Background

  • Acute lung injury that develops within 6 hours after transfusion of 1 or more units of blood or blood components.
  • Increased risk with greater number of transfusions
  • Incidence is 1 in 4000

Definition

  • Acute onset
  • Hypoxemia (PaO2/FiO2 < 300 mm Hg)
  • Bilateral pulmonary opacities on chest x-ray
  • Absence of left atrial hypertension

Pathogenesis

Two-hit hypothesis: first hit is underlying patient factors causing adherence of neutrophils to the pulmonary endothelium; second hit is caused by mediators in the blood transfusion that activate the neutrophils and endothelial cells.

Differential

Can be confused or overlap with TACO or transfusion-associated volume/circulatory overload, which presents similarly but has evidence of increased BNP, CVP, pulmonary wedge pressure, and left sided heart pressures. Patients with TACO tend to improve with diuretic treatment

Supportive tests

  • Echocardiogram 
  • BNP (tends to be low)
  • Transient leukopenia

Treatment

  • Supportive care
  • Lung protective ventilation strategies
  • Fluid restrictive strategy
  • Aspirin (shown to be helpful in animal studies)
  • Pre-washing of stored RBCs prior to transfusion
  • Decrease the amount of transfusions!

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