UMEM Educational Pearls

The followings is a list of unique clinical findings related to a certain sedative-hypnotic overdose:

1) Hypothermia:Barbiturates, bromides, ethchlorvynol (others but these more pronounced)

2) Unique odors: chloral hydrate, ethchlorvynol (which is Placidyl)

3) Bradycardia: GHB (again others but pronounced in this OD)

4) Tachydysrhythmias: chloral hydrate

5) Muscular twitching: GHB, methaqualone, etomidate

6) Discolored urine: propofol (green/pink)

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• Xanthochromia is the yellowish discoloration of the supernatant from centrifuged cerebrospinal fluid (CSF).

• Xanthochromia is an abnormal finding and results from the lysis of red blood cells.

• Xanthochromia is present is CSF in > 90% of patients within 12 hours of subarachnoid hemorrhage (SAH) onset.

Coagulopathy from Acute Liver Failure

• ALF is defined as
  • absence of chronic liver disease
  • acute elevation in AST/ALT accompanied by INR > 1.5
  • any degree of mental status change (encephalopathy)
  • illness less than 26 weeks duration
• The most common cause is acetaminophen toxicity
• Regarding the coagulopathy that develops with ALF:
  • FFP transfusion is not encouraged, as the volume may exacerbate cerebral edema and it has been shown to be ineffective for improving INR elevations
  • The prophylactic transfusion of platelets for extreme thrombocytopenia is also not recommended for similar reasons

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Todays pearl pertains to a great new blog put together by Dr. Michelle Lin, entitled "Academic Life in Emergency Medicine." The blog is superb and is a great resource for anyone interested in academic EM.

Today's posting is about teaching when time is limited and Michelle discusses a really good article written by Irby, et al. This article addresses a topic that is very pertinent to us in the ED, how to teach when it is busy. Isn't it always busy?

Tips from the article:

1. Identify the learner needs (can't be successful without this important step)
2. Teach rapidly (great tips for how to do this in the ED)
3. Provide feedback (students are starving for this)

Want more??? Gotta check out the article....

Here is the link to the site:

http://AcademicLifeinEM.blogspot.com/ 

Enjoy!

Pericarditis is one of the conditions that is often misdiagnosed as STEMI, resulting in "inappropriate" cath lab interventions. In addition to producing STE, pericarditis also may produce dyspnea, diaphoresis, and elevations in TN levels, all of which will mimic true ACS.

On the other hand, pericarditis does NOT produce STE in up to one-third of cases, so the diagnosis may be missed. Non-STE cases of pericarditis occur more often in women, in patients with pericardial effusions, and in patients without preceding viral syndromes.

[Salisbury AC, et al. Frequency and predictors of urgent coronary angiography in patients with acute pericarditis. Mayo Clin Proc 2009;84:11-15.] 

Metacarpal Fractures and Growth Plates:

The growth plates on metacarpals are on the distal end of the bone, except for the 1st metacarpal which is on the proximal end near the carpal bones.

Don't mistake this for a fracture line, however, make sure you get comparison views if they are tender over the area, as this can help you diagnosis a Salter Harris Type 1 fracture.

Noninvasive ventilation use in children has been shown in some trials to be a useful tool to avoid intubation in children with asthma.

Since children with asthma who are intubated have a much higher risk for complications including pneumotharaces and pneumomediastinum this can be a very useful tool.

Bi-Pap is usually started with typical settings of 10 for IPAP and 5 for EPAP and can be titrated up as tolerated to levels of up to 25/20 cm H2O and can be delivered with a set rate or a back up rate.

Albuterol and nebulized epiephrine may be delivered through newer BiPAP machines.  

Signs that BiPAP is working include decreased Respiratory Rate, decreased retractions and accesory muscle use, improved oxygenation saturation

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A patient presents to the University of MD ED in generalized convulsive status epilepticus. Continuous seizure activity that is not stopped by any dose of benzodiazepine [This is actually a very rare entity]. What is your next move?

- Check your basics: Fingerstick blood glucose (hypoglycemics can cause SE)

- Phenytoin is not going to work fast enough, the clock is ticking and the patient's brain cannot handle continuous status epilepticus, after 45-60min permanent neurologic sequelae or death will occur. If the cause is toxin induced, it just won't work.

- In an area where HIV is endemic, you have to consider Isoniazid - an antituberculous drug - and administer antidotal therapy: empiric dosing of vitamin B6 (pyridoxine) 5g IV. It is the only thing that will work.

- From the ED perspective, you will also be using a barbituate though there is evidence to support the use of propofol (after intubation for both). This will hopefully stop the seizure

- General anesthesia is the last chance if all else fails.

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• Several conditions cause increased intracranial pressure (ICP), requiring lumbar puncture (LP) with opening pressure (OP) measurement for diagnostic and therapeutic management.

• Examples of such include:  pseudotumor cerebri, (cryptococcal) meningitis, intracranial mass, and intracranial hemorrhage.

• In order to ensure an accurate measurement, OP should be assessed while the patient is in the lateral decubitus position with the neck and legs in a neutral position.

• Normal OP ranges from 10 to 100 mm H₂0 in children, 60 to 200 mm H₂0 after age 8, and up to 250 mm H₂0 in the obese.  OP > 250 = intracranial hypertension.

• OP (the meniscus level) can fluctuate by 2 to 5 mm H20 with patient's pulse and by 4 to 10 mm H20 with patient's respirations.

• A patient's symptoms of headache and/or neurologic deficit is often relieved by lowering the ICP through slow removal of CSF during LP.  The pressure level should not be lowered by any more than 50% of the initial OP.

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The Maintenance Phase of Therapeutic Hypothermia

Therapeutic hypothermia (TH) has become standard in the care of patients with return of spontaneous circulation from cardiac arrest.  Although the optimal duration of TH is unknown, current literature supports 12-24 hours of cooling to 32-34^oC.  As many of our critically ill patients remain in the ED for seemingly endless lengths of stay, it is likely that most emergency physicians will be managing patients with TH during the maintenance phase of cooling.  Some pearls regarding the maintenance phase:

• Metabolic and hemodynamic homeostasis is critical
• Target volume-cycled mechanical ventilation to maintain a normal pH
• Maintain a MAP > 65 mm Hg
• Maintain blood glucose between 120 - 160 mg/dL
• Frequently check and aggressively replete potassium, magnesium, and phospate

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Elderly are more likely to have non-diagnostic ECGs. The proportion of patients > 85 years of age with NSTEACS who had non-diagnostic ECGs was 43% vs. 23% for patients < 65 years of age. [Elderly are also more likely to have LBBB as well as prior evidence of MI, either one of which can cause some problems with interpretation of acute cardiac ischemia.] The lack of CP combined with non-diagnostic ECGs probably leads to delays and under-treatment of many of these patients.

[Alexander KP, et al. Acute coronary care in the elderly, part I: Non-ST-segment elevation acute coronary syndromes. Circulation 2007;115:2549-2569.]

• Characterized by proteinuria, hypoalbuminemia, edema, and hypercholesterolemia
• Abnormal Vitals:  tachypnea (due to pulmlonary edema); tachycardia (intravascular depletion); hypertension
• Abnormal PE:  peripheral edema, ascites, S3 on ausculation
• UA demonstrates significant proteinuria.
• TX is uniformly with oral steroids.

High Pressure Injection Injuries:

• These injuries initially often have a pretty benign appearance which may result in the injuried person seeking medical treatment late, or the initial medical provider not recognizing the seriousness of the injury.
• Even when treated promptly and aggressively most patients will end up with an amputation of thier finger or have permanent loss of funciton, strength, sensation, or chronic pain.
• In a couple of hours, these injuries tend to result in significant swelling that can lead to compartment syndrome. The swelling can be due to the actual disruption of cells from the high pressure, or due to toxic effects of the injected agent.
• Initial Management should consist of:
  • X-rays: Help to evaluate the extent of the injection.  Radio-opaque solvents will be seen on x-ray, but even radio-lucent solvents may be seen as lucency or air on the x-ray
  • Broad Spectrum antibiotics to prevent infection
  • Corticosteroids to decrease the inflammatory response brought on by the injected agent
  • Tetanus Prophylaxis if needed
  • Emergent hand surgery referral
• Most if not all patients will require emergent debridement of the affected area.

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You have a patient that is on lithium and a serum concentration is checked: 4.3 mmol/l

Therapeutic range is between 0.5 and 1.5 mmol/l

The patient shows no symptoms - is that possible? what do you do?

Answer: highly unlikely that the patient would asymptomatic, at least nystagmus would be present. Remember the symptoms are cerebellar in nature. What may have happened is the blood was drawn in an inappropriate tube. There are green "Lithium Heparinized" tubes in our Emergency Department. They are typically used for cardiac enzymes. This has been a well reported source of error (1)

.

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• 5 to 10% of TIA victims go on to have a complete stroke within 7 days.

• The following validated ABCD clinical prediction rule can be used to risk stratify your next TIA patient in determining who requires an expedited in-patient work-up:

          Risk Factor                                                                        Score

• Age > or = 60                                                                      1

• Blood Pressure (SBP > 140 and/or DBP > or = 90)                    1

• Clinical Features (choose one)

          -- Unilateral weakness                                                           2

          -- Speech impairment w/o weakness                                       1

          -- Other                                                                               0       

• Duration of Symptoms (minutes)

          -- > 60                                                                                2

          -- 10 to 59                                                                           1

          -- < 10                                                                                0

                                                                                              Total 0-6

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Acute Hyponatremia and the Critically Ill

• I just left a busy ED shift during which we had a patient with altered mental status and a serum Na of 115 mmol/L.
• Recall that severe hyponatremia may present with lethargy, disorientation, agitation, nausea/vomiting, altered mental status, abnormal respirations, and seizures.
• For severe, symptomatic hyponatremia, the treatment of choice is 3% hypertonic saline
• At a rate of 100 ml/hr, the serum Na should rise approximately 2 mmol/L per hour.
• In general, the duration of treatment with hypertonic saline is based upon sign and sypmtom improvement.
• For those with more longstanding hyponatremia, serum Na should not be increased by more than 12 mmol in the first 24 hours.

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The Alcoholic Patient in the ED

Well, we have all been there....EMS rolls in with "another drunk guy" found down in the street. The nurses tell you, "he is here all the time...he is just drunk." You should be scared any time you hear this phrase uttered. Always be a little nervous about this group of patients and you won't fall victim to many of the pitfalls that some of us have experienced.

Pearls and Pitfalls in Caring for the Intoxicated Patient in the ED:

• Get a glucose early. Many of these patients are hypoglycemic when they arrive.
• Assume the worst and NEVER tell yourself or others,"He's just drunk." That statement is the kiss of death. Always assume there is occult trauma present. Did they fall and sustain a head bleed, splenic injury, hip fracture?
• Reevaluate during your shift. There is nothing worse than placing an intoxicated patient in a room and ignoring them, only to find out that hours (or shifts) later that they won't wake up.
• Consider a head CT. Although you can't scan them all, have a low threshold to image them. They fall all the time, and you will be surprised at how many subdural hematomas you pick up when you scan this group of patients. If you don't image, perform reassessments frequently during your shift.

T-wave inversions are commonly found in many conditions other than ACS. Many pulmonary conditions, elevated intracranial pressure, LVH, bundle branch block, and young age are associated with T-wave inversions.

T-wave inversions are especially notable in patients with pulmonary embolism, and one study identified a key difference in T-wave inversion patterns in PE vs. ACS: T-wave inversions in leads III and V1 simultaneously were far more likely to be assocaite with PE, whereas the presence of T-wave inversions in I and aVL were almost always ACS.

A key takeaway point is to maintain a broad differential even in the presence of T-wave inversions...it's not necessarily just ACS!

[ref: Kosuge M, et al. Electrocardiographic differentiation between acute PE and ACS on the basis of negatie T waves. Am J Cardiol 2007;99:817-821.]

Manibular Dislocations:

• Mandibular dislocations can be extremely difficult to reduce at times.
• The classic method of reducing a mandible dislocation is for the provider to wrap his thumbs in guaze (to prevent them from being bitten), and while placing his thumbs bilateraly as far posterior on the mandible as possible, he applies downward, and then posterior pressure to reduce the dislocation.
• Significant muscle spasms can result from the dislocation, requiring procedural sedation, but even with sedation it can be very difficult if not impossible to reduce the mandible.
• Dr. Cheng's article, referenced below, describes a new technique, where the provider use both of his thumbs to press down on a single side of the mandible posterior until the side reduces.
  • For a bilateral dislocation, the technique would be to reduce one side and then the other.

Some authors also recommend using rolled guaze to hold the patient's mouth shut so that they do not inadvertantly dislocate their jaw a second time if they happen to yawn while awakening from their sedation.

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Patients who present to the ED with an elevated INR due to vitamin K antagonists many times do not need to be reversed.  Simply holding a dose is all that is usually necessary for patients with an INR < 9.  Fortunately, guidelines published in CHEST are available to help guide management.
 

• INR: >Therapeutic to 5.0 with no bleeding - Lower warfarin dose, or omit a dose and resume warfarin at a lower dose when INR is in therapeutic range
• INR: >5.0 to 9.0 with no bleeding - Omit the next 1 to 2 doses of warfarin, monitor INR more frequently, and resume treatment at a lower dose when INR is in therapeutic range, or omit a dose and administer 1 to 2.5 mg oral vitamin K.* [*This option is preferred in patients at increased risk for bleeding (eg, history of bleeding, stroke, renal insufficiency, anemia, hypertension.]
• INR: >9.0 with no bleeding - Hold warfarin and administer 5 to 10 mg oral vitamin K. Monitor INR more frequently and administer more vitamin K as needed.
• Any INR with serious or life-threatening bleeding - Hold warfarin and administer 10 mg vitamin K by slow IV infusion; supplement with prothrombin complex concentrate, fresh frozen plasma, or recombinant human factor VIIa, depending on clinical urgency. Monitor and repeat as needed.
   

Reference:

Ansell, J, Hirsh, J, Hylek, E, et al. Pharmacology and management of the vitamin K antagonists: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008; (6 Suppl):160s.

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