UMEM Educational Pearls

 Noninvasive Ventilation Pearls

• Multiple studies support the use of noninvasive positive pressure ventilation (NPPV) in acute exacerbations of COPD, acute cardiogenic pulmonary edema, and immunocompromised patients (organ transplant) with hypoxic respiratory failure.
• The timing of NPPV initiation is important.  NPPV should be started as soon as possible, as delays increase the likelihood of intubation
• The best predictor of success is a favorable response to NPPV within the first 1 to 2 hours
  • reduction in respiratory rate
  • improvement in pH
  • improved oxygenation
  • reduction in PaCO2
• Also crucial to NPPV success is a well fitting interface (mask)
• Although patients report greater comfort with nasal masks, they also permit more air leakage through the mouth and have been associated with a higher rate of initial intolerance in the acute setting.
• For acute applications of NPPV in the ED, a full face mask is preferred 

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Evaluating for Pulmonary Embolism During Pregnancy

Highest risk of PE is within the first week postpartum

Acceptable, safe, and medico-legally sound strategies to rule out PE in pregnancy:

• Pulmonary CTA-this strategy is safe and accepted. Plenty of data to support you if you choose this strategy. Some evidence recently that shielding the baby may actually increase scatter radiation to the fetus. Check with your Radiologist. 
• V/Q scan-also an acceptable strategy. Probably more radiation to the fetus. If you choose this test, remember that many experts recommend you insert a foley to drain the bladder (reduces radiation exposure to the fetus). 
• Negative PERC (Pulmonary Embolism Rule Out Criteria) + Negative, trimester adjusted d-dimer level. Adjusted trimester cutoffs for d-dimer in pregnancy are: 1st 750 ng/dL, 2nd 1000 ng/dL, and 3rd 1250 ng/dL. So, figure out what trimester your patient is and if they are PERC - and the d-dimer falls below the cutoff,  you are done. Remember to adjust the pulse to 105 bpm if using the PERC rule for rule out as heart rate goes up in pregnancy.
• Start with lower extremity US, if DVT +, you are done

**For explanation of PERC rule, see earlier pearl.

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The pericardium is electrically silent, and so true acute pericarditis should not be associated with ECG changes. STE actually implies concurrent involvement of the myocardium; i.e. myopericarditis. The greater the degree of myocardium involved, the more ECG changes will develop, including STE, AV blocks, and dysrhythmias. Additionally, myocardial involvement is implied by elevated troponin levels, the magnitude of which is related to the amount of myocardial involvement.

[Imazio M, Trinchero R. Myopericarditis: etiology, management, and prognosis. Int J Cardiol 2008;127:17-26.]

SCAPHOID FRACTURE:

• One of the most frequently missed fractures in the ED
• Most common carpal fracture.
• 10-20% fractures are “occult”
• Significant long-term complications:
  
  • Non-union
  • Avascular necrosis
• Complications more common due to the fact the blood supply comes form from the distal end of the bone.
• The more distal the fracture, the greater risk of complications
• MR remains the best test for occult fx.

•  Intussusception is the telescoping or prolapse of one portion of the bowel into an immediately adjacent segment.
• 90 % occur at the terminal ileum (ie, ileocolic).
• Male-to-female ratio is approximately 3:1.
• Usually seen between 5-9 months of age and 66% of all cases are in the first year of life.
• The classic triad of colicky abdominal pain, vomiting, and red currant jelly stools occurs in only 21% of cases
• Currant jelly stools are observed in only 50% of cases.
• Most patients (75%) without obviously bloody stools have stools that test positive for occult blood.
• If intussusception is strongly suspected, perform a contrast or air  enema without delay.
• Mortality with treatment is 1-3%.
• If untreated, this condition is uniformly fatal in 2-5 days.

• Metformin is the most commonly prescribed oral diabetic mediction in US
• Relative contraindication is in renally impaired patients, they are susceptible to the lactic acidosis
• Lethal adverse effect is the increase production of lactate
• ED patient with an anion gap metabolic acidosis, check for metformin and check the lactate
• The lactic acidosis is often severe (>10 mmol/L) and carries a high mortality rate that has been estimated at >40%
• Correction of pH and emergent hemodialysis are essential

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Top Reasons to call your Neurointerventionalist:

1. Vascular "blowouts" (i.e carotid tumor or trauma). 
2. Symptomatic dissections within 6 hours of onset (i.e. carotid or vertebral).
3. Ischemc Stroke with visible clot on CT angiogram outside of 3-hour IV tPA window.
4. Ischemic Stroke with visible clot on CT angiogram outside of 3-hour IV tPA window or with contraindication for tPA (i.e may be MERCI Device candidate).
5. Subarachnoid hemorrhage of aneurysmal origin.

Hypotension begins at 110 mmHg?

• Many of us use the historical SBP cut-off point of 90 mmHg or less to identify hypotension and shock
• Importantly, there is no data to support this arbitrary value
• Particularly in older patients, hypotension, hypoperfusion, and increased mortality may begin sooner than previously realized
• In this study of over 80,000 patients from the National Trauma Data Bank, a SBP < 110 mmHg was found to be more clinically relevant for identifying hypotension and hypoperfusion
• Take Home Point: strongly consider raising your threshold for identifying hypotension and initiating resuscitation, especially in the older trauma patient.

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Recent Articles from the Critical Care Literature

Duration of adrenal insufficiency following a single dose of etomidate in critically ill patients

Ruling Out PE in Cancer Patients: Use D-Dimer??

Most of us are aware of the data that suports using a highly-sensitive d-dimer combined with low-moderate risk score to r/o PE. Sounds simple enough. What about using d-dimer in a cancer patient to rule it out? Well, this is being studied more and more.

Most of us would be a little uneasy about using a d-dimer as a stand-alone test to r/o PE in a cancer patient. After all, they have cancer, aren't they high risk?

The following study showed that the there was a VERY high negative predictive value and a VERY high sensitivity of a negative d-dimer in this group of cancer patients.

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Both acute pericarditis and myopericarditis are intensely inflammatory. As a result, CRP testing is extremely sensitive for these conditions and is excellent for evaluating their presence or absence.

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Joint Fluid Analysis:

This is hte session in Baltimore for crab eating and beer drinking so we begin to see an increase in Gout pain.  For those that are presenting with their first episode and you are concerned that they might have a septic joint, I am including this pearl to help analysis the fluid you will obtain from arthrocentesis.

 To view a gout crystal click this link.

To view a pseudogout crystal. Click this link

Pearls: 

• A WBC Count >50,000 is septic arthritis until cultures are negative. 
• Due to the wide range of WBC for septic arthritis have a high index of suspicion and do not discount the diagnosis because the WBC count is only 10,000.

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Recent Articles from the Critical Care Literature

Efficacy and Safety of Recombinant Activated Factor VII for Acute Intracerebral Hemorrhage.

Cardiac Involvement in Kawasaki Disease

• 50% can have Myocarditis (tachycardia, decreased ventricular function, arrhythmias, CHF, shock)
• 30% can have Pericarditis In untreated patients;
• 20 – 25% will have Coronary Artery Aneurysm during second and third week of illness Coronary Artery Aneurysms have risk of rupture, thrombosis, or stenosis
• Myocardial Infarction is leading cause of Death due to thrombosis, rupture, or stenosis of a coronary aneurysm
• Treatment with IVIG in the Acute Phase (within 10 days of onset of fever) reduces the risk of coronary artery dilation and aneurysms from 20-25% to < 5 % for coronary dilation and <1 % for giant coronary aneurysm. BUT NOT TO ZERO.

So the Pearl is if you have a pediatric patient with a complaint of Chest Pain, ask if there was any history of Kawasaki Disease and get an EKG ASAP if the answer is yes!

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 ADOLESCENT DRUG ABUSE

• "Pharming" is prescription drug abuse
• Teens will take medications from their home medicine cabinets, mix them in bags together indiscriminately and make "trail mix" to pass around parties
• "Cheese" is a combination of heroin with cough and cold preparations. The heroin concentration in cheese is typically between 2-8% compared to 30% found in black tar heroin, and is considered "starter heroin"

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• The Confusion Assessment Method (CAM) and Mini-Mental State Exam (MMSE)  can be used in combination to effectively differentiate delirium from dementia, respectively.
• CAM relies on observations by family members, caregivers, and clinicians to assess the following four symptoms:
  1. acute confusional onset
  2. inattention
  3. disorganized thinking
  4. ltered level of consciousness

 

• Using CAM, the diagnosis of delirium requires the presence of both the first and second features, plus one of the two other features.
• CAM is 95-100% sensitive and 95% specific for diagnosing delirium in the elderly.
• MMSE is not a diagnostic tool but identifies cognitive impairment suggestive of delirium by assessing orientation, short-term memory, calculation ability, and language (score 18-26 = mild dementia).
• A positive CAM and an MMSE score of > 25 is predictive of delirium.

 

Does this Patient with Diabetes have Osteomyelitis?

• Diagnosis of lower extremity osteomyelitis in the diabetic patient remains challenging
• Bone biopsy with culture remains the gold standard for diagnosis but is not always obtainable
• What clinical features, therefore, raise the likelihood of osteomyelitis?
• In this review, an ulcer size > 2 cm² (LR 7.2), ability to probe to bone using a sterile stainless steel probe (LR 6.4), and an ESR > 70 mm/h were found to be useful in predicting the presence of osteomyelitis
• Clinical features NOT found to be useful included fever (sensitivity 19%), presence of erythema, swelling, or purulence (LR 1), elevated white blood cell count (sensitvity 14%-54%), and superficial swab culture
• A note about radiographic studies:
  • bony changes on plain films may take up to 2 weeks to develop
  • plain films alone are only marginally useful if positive (LR 2.3)
  • MRI is more accurate than bone scan or plain films
  • If you are going to order a radiographic study, your best bet is the MRI

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Does a normal d-dimer rule out aortic dissection?

A lot of research seems to be focused on using d-dimer as a rule-out strategy for acute aortic dissection. The idea is that a d-dimer <500 (which is what we use for ruling out PE in low-mod risk patients) rules out dissection as well.

A few pearls and pitfalls regarding this:

• Studies look very promising, but NO accepted cutoff point (d-dimer) has been defined
• This practice has NOT been widely accepted yet
• A d-dimer <100 ng/dL rules out aortic dissection with a sensitivity of 100%
• A d-dimer of <500 ng/dL rules out aortic dissection with a sensitivity of 98%
• Experts in this area seem to be advocating this as a potential rule out strategy
• Critics of this approach point out the fact that a subset of patients with dissection (those with intramural hematomas-i.e. no intimal tear) may not release d-dimer into the circulation. But almost all studies include patients with this variant and their d-dimers are almost always elevated.

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 Pregnancy and Acute Pulmonary Embolism

Women who are pregnant or in the postpartum period and women who take hormonal therapy are at an increased risk of pulmonary embolism.

Some facts:

• Risk of first episode of venous thromboembolism is 15 times as high in the postpartum period as during pregnancy
• Diagnostic workup and initial ED therapy is the same as it is for non-pregnant patients
• Although there are still some concerns about pulmonary CTA, both the American College of Obstetrics & Gynecology and the American College of Radiology agree that it is safe. It is unknown what happens to fetal nephrons after exposure to circulating contrast in the mother. Despite this, CTA can be used without fear if indicated. 
• Warfarin is a teratogen and should not be used for anticoagulation.

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Low QRS voltage on the ECG has various definitions; here's my simple definition for low voltage...either one of the following:
     If the added QRS amplitudes (whole R wave + S wave) in leads I + II + III total < 15 mm, OR
     If the added QRS amplitudes (whole R wave + S wave) in leads V1 + V2 + V3 total < 30 mm.

The potential causes of  low QRS voltage includes pericardial effusions, pleural effusions, obesity, COPD, infiltrative cardiac diseases (e.g. sarcoid, amyloid), end-stage cardiomyopathies, severe hypothyroidism.

If the patient has NEW low voltage compared to an old ECG, the only real possibilities are pericardial effusion, pleural effusion, and severe hypothyroidism (e.g. myxedema).