UMEM Educational Pearls

Category: Pediatrics

Title: Inborn Errors of Metabolisn

Keywords: Inborn Errors of Metabolism, Hypoglycemia, organomegaly (PubMed Search)

Posted: 7/14/2007 by Sean Fox, MD (Emailed: 7/8/2007) (Updated: 12/9/2022)
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Inborn Errors of Metabolism For the child with neurologic abnormalities, vomiting, acidosis, hypoglycemia, organomegaly, or cardiopulmonary arrest remember to consider Inborn Errors of Metabolism (IEM) on your DDx. There are over 300 disorders of the various biochemical pathways, and while the individual incidence for each disorder may be rare, the collective incidence for IEM is 1-2 / 1,000 births. Treat dehydration and hypoglycemia promptly but FIRST, draw EXTRA blood samples (at UMMS, two adult Green Tops and one adult Red Top) in addition to the basic labs. ==> Once you begin therapy to correct the acid/base disturbance, hypoglycemia, and dehydration the abnormal metabolites present in their serum will be reduced and possibly confound the diagnosis. ==> Draw the extra blood, before your give the NS bolus or the Dextrose! ==> Basic Labs (1) ABG, BMP, Ammonia, U/A are helpful immediately (2) CBC, Blood and Urine Cultures (look for concurrent infection, possibly the inciting event) (3) Urine Reducing Substances, serum organic acids, urine and serum amino acids are also useful

Category: Pediatrics

Title: Bacterial tracheitis

Keywords: Bacterial tracheitis, stridor, croup, epiglottitis (PubMed Search)

Posted: 7/14/2007 by Sean Fox, MD (Emailed: 7/8/2007) (Updated: 12/9/2022)
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Bacterial Tracheitis Considered bacterial tracheitis in a patient who has fever, stridor, and symptoms that do not respond to therapy for croup (racemic epinephrine and steroids). The epidemiology of acute infectious upper airway disease in pediatrics has been altered with immunization against Haemophilus influenza- b and the widespread use of corticosteroids for the treatment of viral croup. Bacterial Tracheitis has replaced epiglottitis and croup as the most common cause of acute respiratory failure. One study found it to be 3 times more likely to cause respiratory failure than croup and epiglotittis combined. The mortality rates had been reported as high as 18% to 40%. Hopkins, A., et al., Changing epidemiology of life-threatening upper airway infections: the reemergence of bacterial tracheitis. Pediatrics, 2006. 118(4): p. 1418-21.

Category: Pediatrics

Title: Syncope

Keywords: Syncope, Brugada, WPW, Prolonged QTc (PubMed Search)

Posted: 7/14/2007 by Sean Fox, MD (Emailed: 7/8/2007) (Updated: 12/9/2022)
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Pediatric Syncope 15-25% of children experience at least one syncopal episode by young adulthood Heart Disease has been the attributed etiology in as high as 10-28% of these cases ==> Historical features suggestive of Cardiac etiology (similar to adults): (1) Onset with exertion (2) No prodome or premonitory symptoms; Resulted in bodily injury (3) Incontinence, Seizure-like activity (4) Abnormal Cardiac Structure or previous cardiac surgery (5) Family Hx of unexplained Death or Accidents (MVC) (6) Required CPR (7) Resulted in neurological insult ==> Get the EKG! Look for (1) WPW (2) Prolonged QTc (3) AV blocks (4) BRUGADA Syndrome Yes, even in kids! Johnsrude, C.L., Current approach to pediatric syncope. Pediatr Cardiol, 2000. 21(6): p. 522-31.

Category: Pediatrics

Title: Pediatric Fever / UTI

Keywords: Fever, UTI, Vesicoureteral Reflux, VCUG (PubMed Search)

Posted: 7/14/2007 by Sean Fox, MD (Emailed: 7/8/2007) (Updated: 12/9/2022)
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Pediatric Fever / UTI UTI is one of the most frequent bacterial infections in children. ==> Vesicoureteral Reflux is diagnosed in 30-40% of children found to have a febrile UTI. ==> Vesicoureteral Reflux can lead to recurrent UTIs and Renal Scarring, which can then lead to hypertension and renal insufficiency. Instruct newly diagnosed patients and families to f/u with PMD to schedule renal imaging (renal ultrasound and VCUG). American Academy of Pediatrics, Committee on Quality Improvement, Subcommittee on Urinary Tract Infection. Practice parameter: the diagnosis, treatment, and evaluation of the initial urinary tract infection in febrile infants and young children Pediatrics. 2000;105:141.

Category: Toxicology

Title: Hydrofluoric Acid (HF)

Keywords: hydrofluoric acid, hypocalcemia, burn (PubMed Search)

Posted: 7/14/2007 by Fermin Barrueto, MD (Emailed: 7/8/2007) (Updated: 12/9/2022)
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Hydrofluoric Acid (HF) Used in glass etching, brick/porcelain cleaning and available in hardware stores Death has been reported after JUST 2-3% body surface area exposure! Systemic toxicity: hypocalcemia, hyperkalemia and hypomagensemia Local effects: paucity of skin findings with tremendous pain Treatment: skin decontamination, correct electrolyte abnormalities and topical calcium gel for local pain Mayer TG, GrossPI. Fatal systemic fluoride due to hydrofluoric acid burns. Ann Emerg Med 1985; 14: 149-153.

Category: Toxicology

Title: Toxic Alcohols

Keywords: Ethylene glycol, methanol, toxic alcohol (PubMed Search)

Posted: 7/14/2007 by Fermin Barrueto, MD (Emailed: 7/8/2007) (Updated: 12/9/2022)
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Toxic Alcohols Unexplained anion gap metabolic acidosis => give fomepizole (antidote) Hypokalemia, hypocalcemia, elevated creatinine => think ethlylene glycol Visual disturbances => think methanol Ketosis without acidosis and high osmol gap => think isopropanol If osmol gap is >70; high specificity for a toxic alcohol ingestion

Category: Toxicology

Title: Acetaminophen Toxicity

Keywords: acetaminophen, hepatic failure, hepatitis (PubMed Search)

Posted: 7/14/2007 by Fermin Barrueto, MD (Emailed: 7/8/2007) (Updated: 12/9/2022)
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Acetaminophen Toxicity Hepatoxicity defined by AST >1000 King s College Criteria to prognosticate hepatic failure and need for transplant: o pH <7.3 o Creatinine >3.4 mg/dL o INR >6.5 o Hepatic encephalopathy Grade III or IV Low phosphate (<1.2 mmol/L) may be predictor of survival and elevated may be indicator of impending hepatic failure. (Especially 48 96 hrs post-ingestion) o Theory is phosphate used in regeneration/healing liver Gow PJ, Sood S, Angus PW. Serum phosphate as a predictor of outcome in acetaminophen-induced fulminant hepatic failure. Hepatology. 2003; 37(3):711.

Category: Toxicology

Title: Botulinum Toxin

Keywords: botulinum toxin, paralysis, heroin (PubMed Search)

Posted: 7/14/2007 by Fermin Barrueto, MD (Emailed: 7/8/2007) (Updated: 12/9/2022)
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Botulinum Toxin Most potent toxin on the planet where 7 picograms IV are lethal to a human Characterized by a descending flaccid paralysis w/o fever bulbar findings 1st Weapon of Mass Destruction but also seen in the IVDA Heroin population Black Tar Heroin outbreak with necrotic ulcers that produced C. botulinum o Most recently in Washington DC 2003 Centers for Disease Control and Prevention (CDC). Wound botulism among black tar heroin users--Washington, 2003. MMWR Morb Mortal Wkly Rep. 2003;52(37):885-6.

Category: Cardiology

Title: Dyspnea

Posted: 7/14/2007 by Amal Mattu, MD (Emailed: 7/8/2007) (Updated: 12/9/2022)
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Elderly are more likely to present with dyspnea (49% [the most common anginal equivalent]), diaphoresis (26%), nausea and vomiting (24%), and syncope (19%) as a primary complaint. The takeaway point: always get that ECG early in elderly patients with these complaints, even when CP is absent!

Category: Cardiology

Title: AMI versus Aneurysm

Posted: 7/14/2007 by Amal Mattu, MD (Emailed: 7/8/2007) (Updated: 12/9/2022)
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AMI versus Aneurysm For ECG distinction between AMI versus ventricular aneurysm, look for reciprocal changes and height of T-waves: 1. Reciprocal ST depression strongly favors AMI. 2. Large T-waves in leads with Q waves and STE is likely AMI. Ventricular aneurysm usually gives you "blunted" or flat T-waves in those leads.

Category: Cardiology

Title: Non-ACS causes of elevation troponins

Keywords: Troponin, cause, Non-ACS (PubMed Search)

Posted: 7/14/2007 by Amal Mattu, MD (Emailed: 7/8/2007) (Updated: 12/9/2022)
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Non-ACS causes of elevation troponins: 1. acute PE 2. Stanford A aortic dissections 3. acute heart failure 4. strenuous exercise (e.g ultra-endurance activities) 5. cardiac toxins 6. ablation therapy/cardiversion 7. cardiac infiltrative diseases 8. post-heart transplant (may persist up to 3 mos) 9. cardiac contusion 10. sepsis 11. rhabdomyolysis

Category: Cardiology

Title: Ventricular dysrhythmias in pregnanc

Keywords: Dysrhythmia, Pregnancy, Treatment, Procainamide (PubMed Search)

Posted: 7/14/2007 by Amal Mattu, MD (Emailed: 7/8/2007) (Updated: 12/9/2022)
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Ventricular dysrhythmias in pregnancy Amiodarone should be considered a last choice in pregnancy. It is the only class D antiarrhythmic, and even short infusions can be associated with fetal hypothyroidism, IUGR, fetal bradycardia, and prematurity. Lidocaine or procainamide are preferred. Also, cardioversion/defibrillation/pacing is considered safe in any stage of pregnancy.

Category: Cardiology

Title: GI Bleed and Myocardial Ischemia

Keywords: GI Bleed, Myocardial Ischemia, ECG (PubMed Search)

Posted: 7/14/2007 by Amal Mattu, MD (Emailed: 7/8/2007) (Updated: 12/9/2022)
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GI Bleed and Myocardial Ischemia Myocardial ischemia or infarction occurs in up to 20% of patients with significant UGI bleeds. For reasons that are uncertain, the majority of these patients have "silent" MIs (i.e. no pain). It's also unclear whether these patients develop MI purely because of hypoperfusion or because the stress causes a plaque to rupture and thrombose. Whenever you have a patient with a massive UGIB, get an ECG early, regardless of whether or not the patient is having chest pain, and if it's concerning, get cardiology involved early as well. anecdote--I've seen 2 patients with STEMI in the presence of an UGIB, one at Mercy and one at UMMS; neither had chest pain; both got transfused, seen by GI, and went cath within several hours; the takeaway--get both consultants involved EARLY!

Category: Critical Care

Title: Pacer Cordis

Keywords: Pacer, Cordis, transvenous (PubMed Search)

Posted: 7/14/2007 by Mike Winters, MD (Emailed: 7/8/2007) (Updated: 12/9/2022)
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Make sure the Cordis is the right size when floating a pacing wire * At some point in your career, you may need to "float" a transvenous pacing wire * When inserting the wire, you need to make sure you have the right size Cordis * In general, a pacing wire should be inserted through a 6F Cordis (0.198 mm) * Many introducer kits have a 7.5F Cordis (0.2475mm) that is used for insertion of a PAC * Blood loss, infection, and air embolism are risks that can occur when the Cordis catheter used is too large Reference: 1. Marcucci L, ed. Avoiding common ICU errors. Philadelphia; Lippincott Williams & Wilkins; 2007:275-6.

Category: Critical Care

Title: TRALI - Transfusion Related Acute Lung Injury

Keywords: Transfusion, Lung, Injury (PubMed Search)

Posted: 7/14/2007 by Mike Winters, MD (Emailed: 7/8/2007) (Updated: 12/9/2022)
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TRALI - Transfusion Related Acute Lung Injury * TRALI has now emerged as the primary cause of transfusion-associated mortality, surpassing infectious complications and ABO mismatch * TRALI is defined as new ALI in a patient receiving, or having just received (within the past 6 hours), a blood product transfusion * All plasma-containing products have been implicated (FFP and platelets are the top offenders) * Clinically, patients present with dyspnea, tachypnea, and hypoxia * CXR findings are consistent with noncardiogenic pulmonary edema * There is no unique treatment for TRALI; most patients have resolution within 96 hours * AVOID diuretics as these patients are often volume depleted Reference: 1. Looney MR. Newly recognized causes of acute lung injury: transfusion of blood products, severe acute respiratory syndrome, and avian influenza. Clin Chest Med 2006;27:591-600.

Category: Critical Care

Title: Critical care of patients with HIV/AIDS - Lactic Acidosis

Keywords: HIV, Lactic, Acidosis (PubMed Search)

Posted: 7/14/2007 by Mike Winters, MD (Emailed: 7/8/2007) (Updated: 12/9/2022)
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Critical care of patients with HIV/AIDS - Lactic Acidosis * Lactic acidosis can be a life-threatening complication of HAART - mortality as high as 77% * It can occur with any of the nucleoside/nucleotide reverse transcriptase inhibitors (most common are didanosine and stavudine) * Common presenting symptoms include abdominal pain, nausea, vomiting, myalgias, and elevation of transaminases * In patients with these symptoms check a lactate -> a value > 5 mmol/L is considered life-threatening * Treatment is supportive care with removal of the offending medication * In anecdotal reports, L-carnitine, thiamine, and riboflavin may reverse toxicity Reference: Morris A, Masur H, Huang L. Current issues in the critical care of the human immunodeficiency virus-infected patient. Crit Care Med 2006;34:42-9.

Category: Critical Care

Title: Serial lactate Levels

Keywords: Lactate, Sepsis, Infection (PubMed Search)

Posted: 7/14/2007 by Mike Winters, MD (Emailed: 7/8/2007) (Updated: 12/9/2022)
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Obtain serial lactate levels in ED patients with infection * Elevated serum lactate is associated with an increased risk of death in critically ill patients with infection * An initial lactate level > 4.0 mmol/l is significant and, in some series, is associated with a mortality of approximately 40% * Obtain serial venous lactate measurements every 3-4 hours * If serial levels remain > 4 mmol/l, or rise, be more aggressive with resuscitation Reference: Trzeciak S, et al. Serum lactate as a predictor of mortality in patients with infection. Inten Care Med 2007;33:970-7.


Category: Critical Care

Title: Start antibiotics ASAP in patients with septic shock

Keywords: Antiobiotics, Sepsis (PubMed Search)

Posted: 7/14/2007 by Mike Winters, MD (Emailed: 7/8/2007) (Updated: 12/9/2022)
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Start antibiotics ASAP in patients with septic shock * For patients with septic shock, start antibiotics within the first hour * For each additional hour that antibiotics are delayed, survival decreases by 7%-8%! * Once you address the ABC's, obtain appropriate cultures, and hang the antimicrobials * Make sure you are providing effective antimicrobials (take a look at the patient's history to see if they have resistant bugs) Reference: Kumar A, et al. Duration of hypotension before initiation of effective antimicrobial therapy is the critical determinant of survival in septic shock. Crit Care Med 2006;34:1589-96.

Category: Critical Care

Title:

Keywords: Right Ventricle, RV Size (PubMed Search)

Posted: 11/5/2019 by Kim Boswell, MD (Emailed: 12/9/2022)
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Rapid Assessment of the RV on Bedside Echo

There are several causes of acute RV dysfunction resulting in a patient presenting to the ER with unstable hemodynamics. Some of these include acute cor pulmonale, acute right sided myocardial infarction and acute submassive or massive pulmonary embolism. While bedside assessment of the LV function is often performed by the ED physician, simultaneous evaluation of the RV can provide crucial information that can help guide therapeutic decisions to prevent worsening of the patient’s clinical condition. A rough guideline to determine RV size and function is below using the apical 4 chamber view.

Normal RV size :            <2/3 the size of the LV

Mildly enlarged RV :       >2/3 the size of the LV, but not equal in size

Moderately enlarged RV:  RV size = LV size

Severely enlarged RV:      RV size > LV size

Patients who are found to have RV dilation should be given fluids in a judicious fashion as the RV is not tolerant of fluid overload. Early diagnosis of the cause of acute RV failure should be sought to guide definitive therapy, but early institution of inotropic support should be considered. Frequent reassessments of biventricular function during resuscitation should be performed.

 

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Category: Trauma

Title: Predicting 30 day readmission in rib fracture patients

Keywords: Rib Fractures, re-admission, 30 day (PubMed Search)

Posted: 12/9/2022 by Robert Flint, MD
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In this retrospective chart review, 3720 admitted trauma patients with rib fractures were looked at for 30 day readmission. 206 patients in the group were readmitted within 30 days.

The authors concluded:

In patients with traumatic rib fractures, those with anticoagulant use, those who actively smoke, those with a psychiatric diagnosis, or those with associated abdominal injuries are at the highest risk of re-hospitalization following discharge. 

 

While this study is retrospective and looks at patients that were sick enough to be admitted, it is a good reminder that patients with rib fractures can have high morbidity and mortality and it gives us certain patient populations in which to show extra concern.

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