UMEM Educational Pearls

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: 2/4/2023)
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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: Toxicology

Title: Valproic acid toxicity

Keywords: Valproic acid (PubMed Search)

Posted: 10/16/2014 by Hong Kim, MD, MPH (Emailed: 2/4/2023)
Click here to contact Hong Kim, MD, MPH

Valproic acid (VPA) is often used to treat seizure disorder and mania as a mood stabilizer. The mechanism of action involves enhancing GABA effect by preventing its degradation and slows the recovery from inactivation of neuronal Na+ channels (blockade effect).

VPA normally undergoes beta-oxidation (same as fatty acid metabolism) in the liver mitochondria, where VPA is transported into the mitochondria by carnitine shuttle pathway.

In setting of an overdose, carnitine is depleted and VPA undergoes omega-oxidation in the cytosol, resulting in a toxic metabolite.

Elevation NH3 occurs as the toxic metabolite inhibits the carbomyl phosphate synthase I, preventing the incorporation of NH3 into the urea cycle.

Signs and symptoms of acute toxicity include:

  • GI: nausea/vomiting, hepatitis
  • CNS: sedation, respiratory depression, ataxia, seizure and coma/encephalopathy (with serum concentration VPA: > 500 mg/mL)

Laboratory abnormalities

  • Serum VPA level: signs of symptoms of toxicity does not correlate well with serum level.
  • NH3: elevated
  • Liver function test: elevated AST/ALT
  • Basic metabolic panel: hypernatremia, metabolic acidosis
  • Complete blood count: pancytopenia

Treatment: L-carnitine

  • Indication: hyperammonemia or hepatotoxicity
  • Symptomatic patients: 100 mg/kg (max 6 gm) IV (over 30 min) followed by 15 mg/kg IV Q 4 hours until normalization of NH3 or improving LFT
  • Asymptomatic patients: 100 mg/kg/day (max 3 mg) divided Q 6 hours.

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Category: Airway Management

Title: Flush-Rate O2 for Preoxygenation prior to RSI

Keywords: RSI, Preoxygenation (PubMed Search)

Posted: 9/13/2016 by Rory Spiegel, MD (Emailed: 2/4/2023)
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During rapid sequence intubation (RSI) we endeavor to avoid positive pressure ventilation, prior to securing a definitive airway. As such, an adequate buffer of oxygen is necessary to ensure a safe apneic period. This process involves replacing the residual nitrogen in the lung with oxygen. It has been demonstrated that a standard nonrebreather (NRB) mask alone does not provide a high enough fractional concentration of oxygen (FiO2) to optimally denitrogenate the lungs (1). Even when a nasal cannula at 15L/min is utilized in addition to the NRB, the resulting FiO2 is not ideal. A bag-valve mask (BVM) with a one-way-valve or PEEP valve has been demonstrated to provide oxygen concentrations close to that of an anesthesia circuit. But its effectiveness is drastically reduced if a proper mask seal is not maintained during the entire pre-oxygenation period (1). This is not always logistically possible in the chaos of an Emergency Department intubation.

A standard NRB with the addition of flush-rate oxygen appears to be a viable alternative. Recently published in Annals of Emergency Medicine, Driver et al demonstrated that a NRB with wall oxygen flow rates increased to maximum levels, rather than the standard 15L/min, provided end-tidal O2 (ET-O2) levels similar to an anesthesia circuit (2). 

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Category: Critical Care

Title:

Keywords: Alarm Fatigue (PubMed Search)

Posted: 5/20/2019 by Robert Brown, MD (Emailed: 2/4/2023) (Updated: 2/4/2023)
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Takeaways

In a study of alarms from 77 monitored ICU beds over the course of a month at the University of California, San Francisco, false alarms were common. Accellerated Ventircular Rhythms (AVRs) made up roughly one third of the alarms, and of the more than 4,361 AVRs, 94.9% were false while the remaining 5.1% did not result in a clinical action.

While this study had a majority of patients in the Med/Surg ICUs, a minority were from the cardiac and neurologic ICUs giving it some broad applicability. This study adds to the literature indicating there are subsets of alarms which may not be necessary or which may require adjustment to increase specificity.

Suba S, Sandoval CS, Zegre-Hemsey J, et al. Contribution of Electrocardiographic Accelerated Ventricular Rhythm Alarms to Alarm Fatigue. American Journal of Critical Care. 2019; 28(3):222-229

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Category: Toxicology

Title: Opioid Prescription Drug Abuse - The Pattern of Abuse

Keywords: opioids, toxicology (PubMed Search)

Posted: 11/20/2014 by Fermin Barrueto, MD (Emailed: 2/4/2023) (Updated: 2/4/2023)
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The pattern of prescription drug abuse continues to center around semisynthetic opioids like oxycodone and hydrocodone. Federal regulations have now raised hydrocodone to a schedule II drug like oxycodone. Despite efforts, the slope for natural and semisynthetic opioids remains steep.  The ED measures of education, limit prescriptions for acute pain, minimize number of days/pills prescribed and utlize the prescription drug monitoring program are some basics that can assist you in better prescribing habits.

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Category: Toxicology

Title: Opioid Prescription Drug Abuse - The Pattern of Abuse

Keywords: opioids, toxicology (PubMed Search)

Posted: 11/20/2014 by Fermin Barrueto, MD (Emailed: 2/4/2023) (Updated: 2/4/2023)
Click here to contact Fermin Barrueto, MD

The pattern of prescription drug abuse continues to center around semisynthetic opioids like oxycodone and hydrocodone. Federal regulations have now raised hydrocodone to a schedule II drug like oxycodone. Despite efforts, the slope for natural and semisynthetic opioids remains steep.  The ED measures of education, limit prescriptions for acute pain, minimize number of days/pills prescribed and utlize the prescription drug monitoring program are some basics that can assist you in better prescribing habits.

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Category: Orthopedics

Title: The association between fluoroquinolone use and tendon injury in an adolescent population

Keywords: tendon, antibiotics, tendonitis (PubMed Search)

Posted: 5/22/2021 by Brian Corwell, MD (Emailed: 2/4/2023) (Updated: 2/4/2023)
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A recent article in Pediatrics attempted to estimate the association between fluoroquinolone use and tendon injury in an adolescent population.

Fluoroquinolones are thought to negatively impact tendons and cartilage in the load-bearing joints of the lower limbs through collagen degradation, necrosis, and disruption of the extracellular matrix.

Population: 4.4 million adolescents aged 12–18 years with filled outpatient fluoroquinolone prescription vs. an oral broad-spectrum antibiotic for comparison.

Fluoroquinolones included ciprofloxacin, levofloxacin, moxifloxacin, and gatifloxacin

Comparator antibiotics included amoxicillin-clavulanate, azithromycin, cefalexin, cefixime, cefdinir, nitrofurantoin, and bactrim.

Outcomes: Primary outcome was 90-day tendon rupture (Achilles, patellar, quadricep, patellar, tibial) identified by diagnosis and procedure codes. Secondary outcome was tendinitis.

Results: The weighted 90-day tendon rupture risk was 13.6 per 100 000 fluoroquinolone-treated adolescents and 11.6 per 100 000 comparator-treated adolescents.

Fluoroquinolone-associated excess risk: 1.9 per 100 000 adolescents; the corresponding number needed to treat to harm was 52 632.

The weighted 90-day tendinitis risk was 200.8 per 100 000 fluoroquinolone-treated adolescents and 178.1 per 100 000 comparator-treated adolescents

Fluoroquinolone-associated excess risk excess risk: 22.7 per 100 000 adolescents; the corresponding number needed to treat to harm was 4405.

Conclusion:

The excess risk of tendon rupture associated with fluoroquinolone treatment was extremely small, and these events were rare. On average, 50,000 adolescents would need to be treated with a fluoroquinolone for 1 additional tendon rupture to occur

The excess risk of tendinitis associated with fluoroquinolone treatment though larger was also small.

Besides tendon rupture, other more common potential adverse drug effects may be more important to consider for treatment decision-making, in adolescents without other risk factors for tendon injury.

 

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Category: Toxicology

Title: Spider bite

Posted: 9/5/2019 by Kathy Prybys, DO (Emailed: 2/4/2023) (Updated: 2/4/2023)
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Question

A 3 year old is bitten by a spider on his right ear which is causing him intense pain, tachycardia, and muscle cramping. Identify the spider.  What is the treatment?

 

 

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Category: Orthopedics

Title: Sports Hernia/Athletic pubalgia

Keywords: Sports Hernia, groin pain (PubMed Search)

Posted: 4/6/2014 by Brian Corwell, MD (Emailed: 2/4/2023)
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Sports Hernia/Athletic pubalgia

 

Hx: Gradually increasing lower abdominal/proximal adductor pain. Usually activity related, resolves with rest. Frequent return despite rest when sports activity resumes.

Most common in athletes who perform cutting/maneuvers in addition to frequent acceleration/deceleration. Think ice hockey and soccer.

Bilateral symptoms not uncommon.

PE:  Resisted sit up with palpation of the inferolateral edge of the distal rectus may recreate symptoms. Similarly, resisted hip adduction may elicit symptoms. 

If for no other reason than to make the diagnosis harder to make, valsalva induced pain may also occur.

Fluoroscopic guided injections can be helpful to isolate the site of pain generation.

First line therapy is rest, non-narcotic analgesia and physical therapy.

With surgery, >80% return to pre injury level of play.

 

http://atlantasportsmedicine.com/orthopedic-surgeon/wp-content/uploads/2009/11/groin-injuries.jpg

 

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Category: Visual Diagnosis

Title: What's the Diagnosis? Case by Dr. Ali Farzad

Posted: 4/7/2014 by Haney Mallemat, MD (Emailed: 2/4/2023) (Updated: 2/4/2023)
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Question

23 year-old female presents complaining of progressive right lower quadrant pain after doing "vigorous" pushups. CT abdomen/pelvis below. What’s the diagnosis? (Hint: it’s not appendicitis)

 

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Category: Critical Care

Title:

Keywords: Right Ventricle, RV Size (PubMed Search)

Posted: 11/5/2019 by Kim Boswell, MD (Emailed: 2/4/2023)
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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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Attachments

Presentation2.pptx (178 Kb)


Category: Neurology

Title: Phantoms in EMS

Keywords: Stroke, EMS, prehospital care, tPA, emergency medical services, fibrinolysis (PubMed Search)

Posted: 5/15/2014 by Ben Lawner, DO (Emailed: 2/4/2023) (Updated: 7/3/2014)
Click here to contact Ben Lawner, DO

The Prehospital Acute Neurological Treatment and Optimization of Medical Care in Stroke Study (PHANTOM-S) was a randomized prehospital  clinical trial. On certain days, a dedicated Stroke Emergency Mobile (STEMO) responded to possible ischemic stroke incidents. Outcomes measured included time to thrombolysis and adverse events such as intracerebral hemorrhage. As opposed to usual prehospital care, a STEMO ambulance was equipped with a CT scanner, point of care laboratory, and a neurologist. According to the study, STEMO use resulted in reduced time to treatment (tPA) without adverse events. 

Though this trial did not specifically measure clinical endpoints, it addresses issues central to the delivery of specialized prehospital care:

1) Are there certain conditions which might warrant a tailored, super-specialized EMS response?
2) Are EMS systems capable of delivering definitive care to the patient as opposed to delivering the patient to definitive care? 

Stateside study has already started.  The Houston Fire Department, in partnership with UTHeath, has already loosed a "Mobile Stroke Unit" on the streets. Like the STEMO, the specialized ambulance will be University hospital based, carry a neurologist, and have the capability to administer tPA. 

STEMO pictures courtesy of the "NeuroEMS Blog"
http://www.neuroems.com/2014/05/14/tpa-in-the-truck-results-of-the-phantom-s-trial/

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Category: Critical Care

Title: Predicting peri-Intubation hypotension

Keywords: peri-Intubation, shock index (PubMed Search)

Posted: 2/7/2017 by Rory Spiegel, MD (Emailed: 2/4/2023)
Click here to contact Rory Spiegel, MD

Identifying patients at risk of hypotension during intubation is not always straight forward. The prevalence of peri-intubation hypotension in the Emergency Department has been demonstrated to be approximately 20%.1 And while certain variables increase the likelihood of peri-intubation hypotension (ex. Shock index> 0.80), no single factor predicts it accurately enough to be used at the bedside.2 In the majority of patients undergoing intubation, clinicians should be prepared for peri-intubation hypotension with either vasopressor infusions or push dose pressors.

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Pulmonary Embolism 

  • In patients with high pretest probability and abnormal vital signs think about cardiac evaluation for pulmonary embolism. McConnell’s sign is most specific but can also be found in acute RCA infarct. TAPSE < 1.8 cm is also a good identifier of RV strain. Remember that patients with COPD or Pulm Htn may have RV dilation at baseline. You may also want to risk stratify patients with PE with labs as well as lower extremity dvt studies. 
  • Let’s give a shout out to Ashley Pickering who recently took some awesome echo images of a patient with a known saddle embolism. 

 

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Category: Critical Care

Title: Oxygenation goals

Posted: 3/11/2009 by Mike Winters, MD (Emailed: 2/4/2023) (Updated: 2/4/2023)
Click here to contact Mike Winters, MD

Oxygenation goals

  • In recent pearls we have talked about 'lung protective' ventilation strategies to reduce volutrauma, barotrauma, and oxygen toxicity.
  • Using 'lung protective' strategies, such as low tidal volumes, results in higher levels of CO2 and a lower pH.  These are tolerated in favor of lower and safer alveolar pressures.
  • In addition to higher pCO2 values and lower pH, oxygenation goals are slightly lower than conventional teaching.
  • In these patients, you want to maintain SpO2 > 88% and PaO2 > 55 mm Hg.

Category: Vascular

Title: D-Dimer in Pregnancy

Keywords: D-Dimer, Pregnancy (PubMed Search)

Posted: 7/9/2008 by Rob Rogers, MD (Emailed: 2/4/2023) (Updated: 2/4/2023)
Click here to contact Rob Rogers, MD

D-Dimer levels are known to be elevated in pregnancy. But how high is too high and can this test be used in the workup of VTE in pregnant patients?

Recent literature indicates that D-dimer levels in each of the three trimesters are approximately 39% higher: 700, 1000, and 1400 ng/dL for each trimester (normal cutoff 500 ng/dL). So, figure out what trimester your patient is in and use the corresponding D-Dimer level for that trimester.

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Category: Visual Diagnosis

Title: An alcoholic with fever and cough

Keywords: fever, cough, alcoholic (PubMed Search)

Posted: 5/7/2012 by Rob Rogers, MD (Emailed: 2/4/2023) (Updated: 2/4/2023)
Click here to contact Rob Rogers, MD

Question

An alcoholic patient presents with a cough, fever, and very foul smelling breath (worse than usual)

What's the diagnosis? And what are the risk factors?

 

 

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Category: Trauma

Title: Injury score comparable geriatric vs non-geriatric patients: Over 65 years do much worse

Keywords: geriatric, trauma, orthopedic injury, injury severity score (PubMed Search)

Posted: 11/5/2022 by Robert Flint, MD (Emailed: 2/4/2023) (Updated: 12/9/2022)
Click here to contact Robert Flint, MD

Trauma patients over age 65 should be cared for by a multidisciplinary trauma team. Here is another study affirming that patients over age 65 do worse when having similar injuries to those under 65. Interestingly, those under 65 had more operative repairs of their orthopedic injuries as well.  

The authors conclude: “Although the ISS and NISS were similar, mortality was significantly higher among patients aged ≥ 65 years compared to patients < 65 years of age”.

 Also it bears further investigation of why those under 65 received more operative repairs

 

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Category: Toxicology

Title: Octreotide for Pediatric Sulfonylurea Poisoning

Keywords: octreotide, sulfonylurea (PubMed Search)

Posted: 4/12/2013 by Bryan Hayes, PharmD (Emailed: 2/4/2023) (Updated: 4/13/2013)
Click here to contact Bryan Hayes, PharmD

Methods: A large retrospective case series evaluated 121 children under 6 years old with hypoglycemia from a sulfonylurea ingestion.

Results:

  • In addition to dextrose, patients who received octreotide had a median of zero hypoglycemic episodes after octreotide (compared to 2 before treatment, p < 0.0001).
  • Median blood glucose concentrations after receiving octreotide were also higher (62 mg/dL vs 44, p < 0.001).
  • Most required only 1 dose of octreotide with no reported adverse effects.


Authors' Conclusion: Octreotide administration decreases the number of hypoglycemic events and increases blood glucose concentrations in children with sulfonylurea ingestion.

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Category: Infectious Disease

Title: Avian Influenza H7N9

Posted: 4/12/2013 by Andrea Tenner, MD (Emailed: 2/4/2023) (Updated: 2/4/2023)
Click here to contact Andrea Tenner, MD

General Information:

-As of April 5th, 14 confirmed cases of a new influenza A virus (H7N9) have occurred in China.  Six of those have died. 

-Presumed transmission via infected poultry in bird markets, and thus far no person-to-person transmission has occurred.

-Likely susceptible to oseltamavir or inhaled zanamivir

 

Area of the world affected:

-China

Relevance to the US physician:

- Suspect in patients with a respiratory illness and appropriate travel history.

- Refer to CDC within 24 hours if test positive for flu A but cannot be subtyped

- If H7N9 is suspected, patients should be under droplet and airborne precautions

 

Bottom Line:

No human-to-human transmission from H7N9 thus far, but the possibility exists.  Any unsubtypeable influenza A patient should be placed on droplet and airborne precautions and oseltamavir or zanamivir started immediately.

 

University of Maryland Section of Global Emergency Health
Author: Andi Tenner, MD, MPH

 

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