UMEM Educational Pearls

A recent, randomized study evaluated two approaches for treating acute pain in an inner-city ED.

• Group 1 received hydromorphone 2 mg. Group 2 received hydromorphone 1 mg (with the option of a second 1 mg dose 15 minutes later).
• 1 hour after the dose, patients were asked if they wanted more pain medication.
• Both groups had an equal proportion of patients decline more pain medication at one hour (67%). 61% of patients in the 1 + 1 group only needed the initial dose of hydromorphone!
• Secondary outcomes and safety measures were also similar between the groups.
• Patients with chronic pain, age >64, weight <150 pounds, or opioid use within last 7 days were excluded. 

Application to clinical practice: For most patients with acute, severe pain in the ED, start with hydromorphone 1 mg. It may be all the patient needs and can potentially avoid giving them extra opioid they don't need.

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• Hold metformin if the patient is at risk for dehydration (eg. vomiting, diarrhea) due to the risk of lactic acidosis
• Medications that stimulate insulin secretion (eg. sulfonylureas, repaglinide, or nateglinide) should be held if the patient is at risk for hypoglycemia
• Patients usually should continue their basal insulin, but may decrease or hold their bolus dosing.
• Finger sticks should be checked every 2-4 hours for those on insulin, or 2-4 times per day for type II diabetics not on insulin.

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Background:

Infection with the Hepatitis C  virus can result in mild to severe liver disease.  Morbidity and mortality from Hep C is increasing the US--many of the 2.7-3.9 million persons with Hep C are not aware of their infection.

Pertinent Information:

- Hepatitis C is now curable for many patients

- Current treatment recommendations are a combination of medications (pegylated interferon plus ribavirin plus a protease inhibitor). 

- Research in this field is very active--treatment is likely to change in the next 3-5 years.

- Risk reduction strategies to protect the liver (i.e. eliminating alcohol and Hep A and B vaccination) are also recommended.

Critical New Recommendation

As much of the disease burden is in the “Baby Boomers,” the CDC  now recommends one time testing of all persons born between 1945 and 1965. 

Bottom Line:

While emergency department management is focused on the treatment of acute complications of liver disease, it is also important to have all age appropriate patients follow-up for testing and treatment of Hepatitis C with their primary care provider.

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Hydroxyethyl starch (HES) is a colloid used for volume resuscitation in critically-ill patients.

Previous studies (click here) have compared crystalloids to HES during fluid resuscitation and have demonstrated that HES has an increased cost with more adverse effects. Adverse effects may include:

• Coagulopathy
• Acute kidney injury
• Increased mortality

In the United States, the Federal Drug Administration published a warning on June 24^th 2013 with respect to the use of HES in critically ill adult patients. Specifically, it warned about the use of HES in patients,

• with sepsis
• with pre-existing kidney injury
• admitted to the ICU
• undergoing heart surgery with cardiopulmonary bypass

If a decision to use HES is made, the FDA warning advises to:

• discontinue use of HES at the first sign of renal injury or coagulopathy
• continue to monitor renal function for at least 90 days (all patients)

Bottom line: With an increased cost and evidence of harm compared to crystalloids, it appears the indications for use of HES are rapidly declining.

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Question

65 year-old male presents with nausea and diffuse abdominal pain, 3 days after knee replacement surgery. What's the diagnosis?

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• Statin therapy significantly reduces the risk for thrombotic events
• A recent study sought to determine the impact of short-term intensive statin therapy on intracoronary plaque lipid content
• 87 patients with multivessel CAD undergoing percutaneous coronary intervention and at least 1 other severely obstructive were randomized to intensive (rosuvastatin
  40 mg daily) or standard-of-care lipid-lowering therapy
• Upon follow-up, median reduction (95% confidence interval) was significantly greater in the intensive versus standard group ( p=0.01)
• Short-term intensive statin therapy in small trials reduces lipid content in obstructive lesions and further large studies with longer follow-up are warranted

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Sternal fractures

• Initially thought to be associated with high mortality due to associated injuries though newer studies show the mortality rate is about 1%.
• Can be associated with
  • Rib fractures
  • Mediastinal injury
  • Cardiac Contusion
  • Pneumothorax
  • Aortic dissection
  • Pulmonary Contusion
• The diagnosis can be made with plain radiographs, but a fracture can be missed on a regular PA and Lateral Chest Xray.  Ask for dedicated sternal views to better define the fracture
  • CT Chest is only needed if you are concerned about associated injuries
• Obtain an ECG on arrival and at 6 hours to ensure there are no signs of a myocardial contusion
  • ST segment changes, arrhthymias
• Treatment is supportive. Provide adequate pain control and treat associated injuries

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When reviewing a patient's medication list, there are always some that should catch your eye. Digoxin is one since we can measure it, has a low therapeutic index and elimination is effected when renal function is diminished. Another drug that should catch your eye is SOTALOL. Renally cleared and affected by even a minimally lower than normal magnesium. The toxic effect even at therapeutic levels is torsades de pointes.

One study, in a 736 bed hospital, showed 89% of patients prescribed sotalol were on an inappropriate dose due to renal function and an odds ratio of 3.7 increased re-admission rate at 6 months for the patients on the inappropriate dose of sotalol.

We can catch this in the ED. Involve your pharmacist, ED pharmacist or local toxicologist for dosing calculations.

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General Information:

An estimated 70 children in the world die every 5 minutes-- 99% of these deaths are from developing countries, half in Sub-Saharan Africa , and two-thirds from preventable or easily treatable causes.

Area of the world affected:

One study examining the quality of hospital emergency care of 131 children in 21 hospitals in 7 developing countries found:

·       66% of hospitals did not have adequate triage; 41% of patients had inadequate initial assessment;

·       44% received inappropriate treatment and 30% had insuf cient monitoring.

·       Frequent essential drugs, laboratory and radiology services supply outages

·       Staffing and knowledge shortages for medical and nursing personnel

Relevance to the US physician:

The International Federation of Emergency Medicine (IFEM) used a consensus approach to develop the International Standards for Emergency Care of Children in Emergency Departments, published in July 2012.

·       The standards covering initial assessment, stabilization and treatment, staf ng and training

·       Guidelines for coordinating, monitoring and improving the pediatric emergency care are addressed

Bottom Line:

The IFEM International Standards for Emergency Care of Children provide an excellent resource for both clinicians and hospital managers in developing countries.

University of Maryland Section of Global Emergency Health

Author:Terrence Mulligan DO, MPH,FIFEM, FACEP, FAAEM, FACOEP, FNVSHA

--thanks and acknowledgments to Baljit Cheema, University of Cape Town and Stellenbosch University, South Africa

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CVP and Fluid Responsiveness

• Central venous pressure (CVP) has been used over the last 50 years to assess volume status and fluid responsiveness in critically ill patients.
• Despite widespread practice habit, CVP has not been shown to reliably predict fluid responsiveness in the critically ill.
• In a recent updated meta-analysis, Marik et al reviewed 43 studies, totaling over 1800 patients.
  • 57% of patients were fluid responders
  • The mean CVP was 8.2 mm Hg for fluid responders and 9.5 mm Hg for non-responders
  • For studies performed in ICU patients, the correlation coefficient for CVP and change in cardiac index was just 0.28.
• Bottom line: Current literature does not support the use of CVP as a reliable marker of fluid responsiveness.

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Question

Name three differential diagnoses based on the CXR below.

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Bifascicular block

1. Right bundle branch block (RBBB) + left anterior fascicular block (LAFB) 
2. RBBB + left posterior fascicular block (LPFB)
3. Complete left bundle branch block (LBBB)

Incomplete Trifascicular block

1. Bifascicular block w/1^st degree AV block    *classically referred to as “trifascicular block”*
2. Bifascicular block w/2^nd degree AV block
3. Alternating LBBB + RBBB

Complete Trifascicular block

1. Bifascicular block w/3^rd degree AV block 

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Tennis Elbow

The tendon usually involved in tennis elbow is called the Extensor Carpi Radialis Brevis (ECRB).

 The ECRB  muscle helps stabilize the wrist when the elbow is straight.

Ask the patient to straighten the arm at the elbow and then perform resisted long finger extension. This will stress the ECRB and reproduce the pain. One can also ask the patient to lift the top of a chair in the air with the elbow extended.

General Information:

Hepatitis A is a food-borne illness that is prevalent in developing countries.  Currently in the US we are experiencing an outbreak in 8 states related to a frozen blend of organic berries. (Linked to Townson Farms brand sold at Costco and Harris Teeter)

Clinical Presentation:

- Case definition: sudden onset of S/S + jaundice or elevated liver enzyme levels

- S/S: nausea, anorexia, fever, malaise, abdominal pain

Diagnosis:

- Hepatitis A IgM

Treatment:

- Exposed patients should be given the Hep A vaccine within 2 weeks of exposure

- Exposed patients >40 yrs old, <1 yr old, immunocompromised, or with chronic liver disease: give immunoglobulin instead (risk of more severe disease)

- Supportive care

Bottom Line:

Patients potentially exposed to Hepatitis A in the past 2 weeks should be given either the vaccination or immunoglobulin, depending on comorbid conditions.  Treatment of active infection is supportive.

University of Maryland Section of Global Emergency Health

Author: Andi Tenner, MD, MPH

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Keep Immune Thrombocytopenic Purpura (ITP) in your differential for patients with thrombocytopenia and evidence of bleeding. Although ITP has classically been described in children, it can occur in adults; especially between 3^rd- 4^th decade.

Thrombocytopenia leads to the extravasation of blood from capillaries, leading to skin bruising, mucus membrane petechial bleeding, and intracranial hemorrhage.

ITP occurs from production of auto-antibodies which bind to circulating platelets. This leads to irreversible uptake by macrophages in the spleen. Causes of antibody production include:

• Medication exposure
• Infection (usually viral), including HIV and hepatitis
• Immune disorders (e.g., lupus)
• Pregnancy
• Idiopathic

Suspect ITP in patients with isolated thrombocytopenia on a CBC without other blood-line abnormalities. Abnormality in other blood-line warrants consideration of another diagnosis (e.g., leukemia).

ITP cannot be cured; treatments include:

• Steroid to suppress antibody production (first-line therapy)
• Intravenous immunoglobulin (IVIG)
• IV Rho immunoglobulin (for Rh+ patients only)
• Rituximab +/- dexamethasone
• Splenectomy (rare cases of massive hemorrhage refractory to pharmacologic treatment)

Stanford type A (proximal) aortic dissection accounts for ~60% of all aortic dissections

Classic treatment includes direct surgical replacement of the ascending aorta w/prosthetic graft (+/- AV  aortic repair/replacement)

~20-30% of these patients (*institutional dependent) are considered poor candidates for surgery and receive only medical management, which innately results in substandard outcomes

In this study those who were considered poor candidates for surgical repair underwent novel endovascular treatment

Endovascular repair in this study was considered both appropriate and improved traditional medical outcomes in patients who were considered poor candidates 

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Trapezium Fractures

• The trapezial body is often fractured due to an axial load through the thumb
• The trapezial ridge is often fractured during a fall on an outstretched hand
• Accounts for 1% to 5% of all carpal fractures.

Suspect the Diagnosis when you note

• Tenderness  over trapezium 
• Often have increased pain with axial loading of thumb.
• Point tenderness at the volar base of the thumb just distal to the scaphoid, at the base of the first metacarpal.
• Since the trapezium is obscured by superimposed bones in PA and lateral views, fractures are most easily identified on the oblique radiographs

If you are suspected the diagnosis oblique radiographs or a CT scan of the wrist will note the fracture the best.

Treatment consists of placing the patient in a thumb spica splint.

• enterovirus which lives in digestive tract, and is highly contagious
• outbreaks worse in summer and fall, but is a self-limited illness
• causes mild flu-like symptoms such as fever, headache, muscle aches, sore throat. with fever usually lasting less than 3 days
• hand, foot, and mouth disease: syndrome of painful blisters in oropharynx and plams of hands and soles of feet
• herpangina: painful blisters in oropharynx, usually posterior in location
• hemorrhagic conjunctivitis: eye pain with injected conjunctivia
• serious complications include: viral meningitis and encephalitis, myocarditis, and secondary bacterial infections

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In the treatment of acetaminophen poisoning with N-acetylcysteine (NAC), the PT/INR can be slightly elevated even in the absence of hepatotoxicity. Considering Prothombin Time (PT) is one of the criteria used to assess severity of liver damage in this setting, it is important to know how much the PT/INR can be affected by NAC and if it has an actual effect on coagulation factor levels.

1. N-acetylcysteine has been shown to slightly increase the PT) by up to 3.5 seconds in healthy volunteers.
2. A more recent study by the same authors demonstrated a reduction in vitamin K-dependent clotting factor activity (II, VI, IX, and X) after NAC administration in healthy volunteers.

Clinical Practice Pearls

• The elevation in PT/INR after NAC administration is real, not simply laboratory interference.
• However, the PT/INR elevation and decrease in coagulation factors is modest and not likely clinical signficant.
• Many poison center guidelines allow for an INR up to 2 to be considered 'normal' to account for this phenomenon in this setting.

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