Thrombolytic Therapy for Pulmonary Embolism

Current, FDA-approved thrombolytic therapy for PE:

• tPA 100 mg over two hours-infusion
• Heparin drip should be turned off during tPA infusion and turned back on ONLY after PTT has fallen to 2 X normal
• Other drugs are being used-like Tenecteplase (TNKase), but strictly speaking, not FDA approved for thrombolysis of PE
• Most studies to date do not show that catheter-based delivery of lytics is safer than systemically administered lytics
   

Up to 25% of elderly patients with appendicitis are initially sent home from the ED, an indication of the high misdiagnosis rate for appendicitis in the elderly population. Why are elderly patients so often misdiagnosed when they have appendicitis? The answer is simple....they present very atypically.

• The classic migratory pattern (periumbilical pain that migrates to the RLQ) is absent in > 50%
• Nasea, vomiting, and anorexia are each absent in > 50%
• Fever is absent in up to 50%
• Guarding and rebound are absent in 50%
• The WBC is normal in up to 45%
• Up to 15% have pyuria or bacteriuria, leading to misdiagnoses of UTI

Expect the atypical in elderly patients!
 

Show References

Wound Care:

Patients and many providers want to irrigate or wash a wound with an antiseptic solution in order to decrease the risk of infection.  Most studies have shown that irrigation whether with tap water or sterile water is effective enough in reducing bacterial counts in a wound so does adding an antiseptic solution offer any additional benefit.

It turns out that hydrogen peroxide, and iodine based solutions can actually hinder wound healing as they causes delays in the migration and proliferation of fibroblasts at concentrations that are not even bactericidal.  Chlorhexidine, and silver containing antiseptics [i.e.: silver sulfadiazine and silver nitrate] are bactericidal at concentrations that do not affect fibroblasts.

So in the end, if you feel the need to use an antiseptic, use chlorhexidine or a silver containing antiseptic.  The use of hydrogen peroxide and iodine based solutions should be abandoned as they are not even bactericidal at concentrations that have profound affects on the fibroblasts.

Show References

There are a several classes of medications that can kill a toddler with a single dose. Toddlers are particularly susceptible due to their low weights and propensity to place everything in their mouths.

1. Calcium channel blockers
2. Camphor-containing rubs
3. Opioids/opiates
4. Oil of wintergreen/ aspirin
5. Cyclic antidepressants
6. Topical blood pressure patches (clonidine)
7. Eye drops and nasal sprays (oxymetazoline)
8. Sulfonylureas
9. Antimalarial drugs (cloroquine)

Show References

• Acute optic neuritis (ON) must be considered in any patient presenting with vision loss, especially if unilateral and associated with discomfort on eye movement.

• ON is a finding often (50%) associated with Multiple Sclerosis (MS), with or without other classic MS abnormalities such as transverse myelitis, internuclear ophthalmoplegia, and paresthesias. 

• A normal fundoscopic examination does not rule out ON, as 50% of acute cases affect the retrobulbar space.

• Positive pertinent clinical findings may include an afferent pupillary defect in the affected eye and/or visual acuity abnormality, ranging from subtle deficit to total blindness. 

Show References

Show References

[from Hals G. Common diagnoses become difficult diagnoses when geriatric patients visit the emergency department, part I. Emergency Medicine Reports 2010;31(9):101-110.]

Septic Arthritis versus Arthritis:

Though CRP and ESR levels are significantly higher in patients that have septic arthritis, a 1998 study showed that there is extensive overlap between patients with septic arthritis  crystal assoicated arthritis that both CRP and ESR have low sensitivity, specificity and predictive values.  Peripherial WBC counts did not differ between the two disease processes..

The morale of the story:  If you are suspecting septic arthritis you need to  perform an arthorcentesis to analysis the synovial fluid.  Systemic biomarkers can not support one diagnosis over the other.

Show References

• in the US, the right of an adolescent (<18yrs) to seek and receive treatment without parental consent varies from state to state.
• usually, the right to self-consent for treatment is specified through public health statutes when there is clinical suspicion of a STD
• many states allow minors to seek help for pregnancy, contraception, substance abuse, and mental health issues without parental consent

some absolutes or almost always cases include the following:

1. emancipated minors: moved outside of the home and support themselves financially, married, in the military, or has a child
2. emergencies: patient is unconscious or unable to give consent
3. mature-minor: possess the ability to comprehend the risks and benefits of treatment/therapy

Show References

Scombroid is caused by ingestion of preformed histamine on skin of fish.

• Naturally occurring histidine on scaly fish converted to histamine by surface bacteria - often fish left out too long, refrigeration will prevent the conversion.
• Bacteria responsible are Morganelli morganii and K. pneumoniae
• Fish: tuna, mahi mahi, amberjack, bonito, mackerel, albacore
• Fish usually appears normal though meat may tast peppery
• Patient presents minutes/hrs flushed, urticaria, HA, N/V
• Self-limited and improve within hrs even without treatment
• Antihistamines and rarley epinephrine will be needed

• There are over 6 million stroke survivors in the United States, many of whom participate in helpful support groups, along with their loved ones and caregivers.

• Stroke recovery is often a lifelong journey.

• Prognosis and outcomes significantly improve with early, stroke rehabilitation at stroke-focused units.

• Stroke rehabilitation consists of several areas of focus such as physical, occupational, and visual therapies.

Postcardiac Arrest Syndrome: Controlled Reoxygenation

• In previous pearls, Dr. Marcolini has highlighted the poscardiac arrest syndrome (PCAS), comprised of brain injury, myocardial dysfunction, systemic ischemia/reperfusion response, and persistent precipitating disease.
• Not surprisingly, postcardiac arrest brain injury is a major cause of morbidity and mortality, accounting for > 60% of deaths in some studies.
• In addition to therapeutic hypothermia, consider "controlled reoxygenation" in order to optimize neurologic outcome.
• Animal data has demonstrated that too much oxygen may worsen neuronal damage during the initial resuscitation phase.
• Take Home Points:
  • Use a minimum amount of F_iO₂ to maintain S_pO₂ of 94-96%
  • Avoid unnecessary arterial hyperoxia

Show References

Massive Pulmonary Embolism and Response to Fluids and Mechanical Ventilation

Massive pulmonary embolism leads to acute pulmonary hypertension and right ventricular overload. This leads to release of troponin and a "bowing" of the interventricular septum on echocardiography. Deviation of the septum then leads to a decrease in left-sided cardiac output. 

A few interesting clinical pearls:

• Administration of IV fluids to patients with massive PE often leads to a decrease in BP. This happens as a result of increasing preload causing further bowing of the septum and a subsequent further drop in left ventricular cardiac output, leading to hypotension. 
• Patients with massive PE who require intubation often demonstrate an increase in BP due to positive pressure ventilation causing a drop in preload and a reduction of septal bowing into the left ventricle.

Elderly patients have slightly lower body temperatures than younger adults, and as a result it has been suggested that "fever" be defined as anything > 99 degrees F. One study found that by lowering the definition to this number improved the sensitivity and specificity to 83% and 89%, respectively.

from Hals G. Common diagnoses become difficult diagnoses when geriatric patients visit the emergency department, part I. Emergency Medicine Reports 2010;31(9):101-110.

study referred to: Castle SC, et al. Fever response in elderly nursing home residents: are the older truly colder? J Am Geriatric Soc 1991;39:853-857.

Osteomyelitis:

• An acute or chronic inflammatory, infectious process of bone.  Can occur via hematogenous spread or direct innoculation of bone.
• Can be diagnosed on plain radiographs but bony changes might not be evident for 14-21 days.  By 28 days 90% of patients will demonstrate a bony abnormality.
• Initially plain radiographs will show periosteal elevation. Later cortical or medullary lucencies are seen.
• Additional tests to help make the diagnosis include:
  • Three phase bone scan: often not practical for the ED.
  • CT Scan: better in areas with complex anatomy [i.e.:spine, pelvis, ,mid and hind foot]
  • MRI: most effective in early detection and to guide surgical approaches.  Sensitivity is estimated at 90-100%.

Show References

Hyperpronation: This reduction technique for a nursemaid's elbow (radial head subluxation)  has been found to have better first attempt success than classic supination/flexion technique.  (Pediatrics July '98).  Support the elbow with a finger on the radial head, and forcefully hyperpronate.  

• Technique may be less painful as well.  
• Reexamine after five minutes, and normal function should be returned
• Xrays are generally unnecessary unless history and physical are not consistent with nursemaid's elbow, symptoms for greater than 12 hours, or reductions attempts are unsuccessful
• Supination/Flexion may be attempted after two failed hyperpronation attempts 

Attachments

1005212340_Hyperpronation_technique.jpg (54 Kb)

Stroke strikes F.A.S.T. and must be recognized quickly for optimized management.

The following Face, Arms, Speech test, known as F.A.S.T., is an easy and quick bedside teaching tool that can be used to spread awareness about how to recognize and respond to stroke symptoms:

F = Ask person to smile. Does one side of face droop down?

A = Ask person to raise both arms. Does one arm drift downward?

S = Ask person to say a simple phrase. Does speech sound slurred or strange?

T = If any of the above findings are observed, it's time to call 911 immediately.

Show References

A single episode of hypotension portends a worse outcome for septic patients.  The restrospective analysis by Marchick et al of 700 patients showed that mortality was 10% vs 3.6% for septic patients whose SBP dropped below 100 even once.  It was also noted that the lower the SBP, the worse the in-hospital mortality.

So, not only do we need to remember to watch blood pressure closely for head-injured patients, but for septic patients as well!

Show References

Teaching When Time is Limited

We all know how difficult it can be to teach in the ED when it is busy. So how do the experts do it when there is so little time?

Just a few considerations that might make your teaching more effective and easier to do when it is busy:

• Identify the learner's needs. The time-saving rule of thumb: target, then teach. After all, how do you know what to teach if you don't know what the learners knows or needs.
• Teach rapidly. And I mean rapidly. Many of us have really come to realize over the years that less is better. As Amal says, be a sniper and don't use a shotgun. Teach one thing quickly and move on. Pick a pearl (or pitfall, etc.), lock and load, then deliver it...then STOP teaching. Much more effective than spending 20 minutes talking about stuff nobody will ever remember!
• Provide some type of feedback. Feedback is one of the most underused yet powerful teaching tools available. 

Show References

Elderly patients should be considered immunocompromised for several reasons:
1. T cell function and reduced cellular immunity occur as we get older.
2. B cell antibody production decreases.
3. Host defenses against infection are reduced with aging, such as reduced circulation and thinning skin.
4. Miscellaneous factors, such as malnutrition and co-existing illnesses contribute to increased risk of infection as well.

[Good reference and suggested reading: Hals G. Common diagnoses become difficult diagnoses when geriatric patients visit the emergency department: Part I. Emergency Medicine Reports 2010;31(9):103-111.]