UMEM Educational Pearls

Takeaways

Full cohort analysis idarucizumab for dabigatran associated bleeding was recently published in NEJM.

This study evaluated the laboratory correction of elevated ecarin clotting time or diluted thrombin time induced by dabigatran and time to either cessation of bleeding (Group A: patients with GI bleeding, traumatic bleeding, or ICH) or time to surgery (Group B: patients requiring surgical intervention within 8 hours).

Findings

Group A (n=301): Median time to the cessation of bleeding was 2.5 hours in 134 patients.

HOWEVER:

• Bleeding cessation could not be determined in 67 patients
• Cessation of bleeding could not be assess in 98 patients with ICH
• Bleeding stopped spontaneously in 2 patients.

Group B (n=202): Median time to intended surgery after infusion of idarucizumab was 1.6 hours.

• Normal hemostasis in 184 patients (93.4%), mildly abnormal in 10, and moderately abnormal in 3.
• Many received PRBC and other blood products during surgery

Laboratory markers:

100% reversal of abnormal ecarin clotting time or diluted thrombin time within 4 hours after the administration

Mortality

• 5 Day: Group A: 6.3% vs. Group B: 12.6%
• 30 Day: Group A: 13.5% vs. Group B: 12.6%
• 90 Day: Group A: 18.8% vs. Group B: 18.9%

Conclusion

Authors concluded thate idaurcizumab is an "effective" reversal agent for dabigatran.

Overall, the findings are more promising compared to the interim analysis that was published in 2015.

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• CSF:blood glucose ratio is a useful characteristic in differentiating bacterial meningitis from viral meningitis. 
• Normal CSF glucose is at least 2/3 of serum glucose level.
• In bacterial meningitis, CSF:blood glucose ratio is usually <0.4
• Rousseau et al. conducted a study comparing CSF:blood glucose ratio obtained using a bedside glucometer with the laboratory.
• They found the optimal cutoff of CSF:blood glucose ratio using a bedside glucometer is 0.46 compared to 0.44 using the laboratory.
• This proof-of-concept study suggests that a point-of-care glucometer can be used for rapid diagnosis of abnormal CSF:blood glucose ratio in the evaluation of meningitis.

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Hyponatremic Encephalopathy

• Hyponatremic encephalopathy is a true emergency and due to hypoosmolar-induced cerebral edema.
• In contrast to the asymptomatic patient with hyponatremia, treatment of hyponatremic encephalopathy is determined by symptoms and not the duration of hyponatremia.
• Clinical manifestations include nausea, vomiting, headache, confusion, seizures, respiratory failure, and coma.
• Hypertonic saliine is the treatment of choice
  • Administer 2 ml/kg 3% hypertonic saline (100 ml in many cases)
  • This will typically raise serum sodium 2 mEq/L
  • In most cases, a 4-6 mEq/L rise will reverse neurologic symptoms

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Takeaways

Febrile seizures occur in children 6 months through 5 year olds.  A complex febrile seizure occurs when the seizure is focal, prolonged (> 15 min), or occurs more than once in 24 hours.

The prevalence of bacterial meningitis in children with fever and seizure after the H flu and Strep pneumomoniae vaccine was introduced is 0.6% to 0.8%.  The prevalence of bacterial meningitis is 5x higher after a complex than simple seizure.

From the study referenced, those children with complex febrile seizures who had meningitis all had clinical exam findings suggestive of meningitis.  More studies are needed to provide definitive guidelines about when lumbar punctures are needed in these patients.

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Takeaways

In patients presenting to the ED with suicidal ideation, physicians should not use currently available risk-assessment tools in isolation to identify low-risk patients who are safe for discharge. The best approach to determine risk is an appropriate psychiatric assessment and good clinical judgment, taking patient, family, and community factors into account. (Level C Recommendation, based upon the quality of the research.) 

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Catastrophic Antiphospholipid Syndrome (CAPS):

A life-threatening “thrombotic storm” of multi-organ micro & macro thrombosis in patients with antiphospholipid syndrome (known or unknown).

Triggered circulating antibodies (usually by infection, but can be prompted by malignancy, pregnancy, and lupus itself) cause endothelial disruption and inflammation leading to prothrombotic state, commonly with SIRS response.

Mortality is high at an estimated 40%.

Confirm diagnosis with antiphospholipid antibody titers.

Treat ASAP with unfractionated heparin, corticosteroids, and Hematology consultation for plasma exchange and/or IVIG.

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• It most commonly occurs in patients with preexisting pituitary adenomas, but 3 out of 4 patients with pituitary adenomas are unaware of their diagnosis.
• Patients may acutely present with thunderclap headache, with or without visual field deficits or cranial nerve dysfunction. They may also have meningeal symptoms due to extravasation of blood into the subarachnoid space.
• Endocrine dysfunction is common but not readily diagnosed in the ED.
• Symptoms may be triggered by some hormonal treatments (e.g. GnRH agonists for prostate CA), head trauma, angiographic procedures, or anticoagulation therapy.
• CT is diagnostic in only one-third of cases, but can reveal the intrasellar mass in 80% of cases, and therefore should be the initial test. Blood may be missed in subacute cases.
• MRI is the test of choice, with a sensitivity of over 90%.  

Bottomline: Keep pituitary apoplexy in your differential when considering SAH or meningitis, especially in the presence of risk factors, and have a low threshold to order an MRI. 

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Takeaways

Take Home Point: In patients with diabetic gastroparesis, haloperidol may be an effective adjunctive treatment to prevent hospitalizations and reduce opioid requirements. 

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Patients with psychiatric disorders are found globally, with a recent global burden of disease estimate that mental illness accounted for 32.4% of years lived with disability and 13.0% of disability-adjusted life-years.

The American College of Emergency Physicians just published a methodological rigorous clinical policy entitled “Critical Issues in the Diagnosis and Management of the Adult Psychiatric Patient in the Emergency Department.”

One question they sought to answer was “In the alert adult patient presenting to the ED with acute psychiatric symptoms, should routine laboratory tests be used to identify contributory medical conditions (nonpsychiatric disorders)?”

Their assessment was: “Do not routinely order laboratory testing on patients with acute psychiatric symptoms. Use medical history, previous psychiatric diagnoses, and physician examination to guide testing.” This was a Level C recommendation, based upon the quality of the research.

Bottom Line: Current literature does not support routinely ordering laboratory testing on patients with acute psychiatric symptoms. However, the quality of the evidence was not strong and local clinical context should be considered.

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Takeaways

--RV systolic function is negatively affected by high RV afterload

--High mean airway pressures on the ventilator (particularly in modes such as APRV [airway pressure release ventilation]) can induce RV dysfunction

*****CLICK BELOW FOR A GREAT CASE!!!*****

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Takeaways

The answer appears to be ... it depends.

Early Oseltamivir Treatment in Influenza in Children1-3 Years of Age: A Randomized Controlled Trial

A study in 2010 out of Finland by Heinonen, et al showed that if given in the first 12 hours of symptom onset to otherwise healthy pediatric patients between the age of 1-3 years:

-  decrease incidence of acute otitis media by 85%

-  no difference if given within 24 hours

Among children with influenza A, oseltamivir started within 24 hours of symptom onset

-  shortened medium time to resolution of illness by 3.5 days (3.0 versus 6.5) in all children

- shortened median time to resolution of illness by 4.0 days in UNvaccinated children

- Reduced parental work absenteeism by 3 days

*  no differences were seen in children with influenza B *

Limitations***

- Single Center study in Finland

- The authors received support from the drug manufacturer

- The sample size of children with confirmed influenza cases with small (influenza A: 79, influenza B: 19)

Takeaway:

If you have a patient between the age of 1-3 years with very early symptoms concerning for flu, a positive rapid influenza A test could allow you to cut her symptoms by 3 days, prevent complications, and allow parents to go back to work sooner.

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Patients with severe salicylate poisoning may require endotracheal intubation due to fatigue from hyperventilation or mental status change.

A previously published study (Stolbach et al. 2008) showed that mechanical ventilation increases the risk of acidemia and clinical deterioration.

A small retrospective study investigated the impact of hemodialysis (HD) in intubated patients with salicylate poisoning.

Findings:

53 cases with overall survival rate of 73.2%

In patients with salicylate level > 50 mg/dL

• No HD: 56% survival (14/25)
• HD: 83.9% survival (0/9)

If salicylate level > 80 mg/dL

• No HD: 0% survival (26/31)
• HD: 83.3% survival (15/18)

Bottom Line:

There is moratality benefit of HD in intubated salicylate-poisoned patient.

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Improving Resuscitation Performance

• Resuscitating the critically ill patient can often be quite stressful.
• Stress has been shown to decrease the quality and effectiveness of decisions, decrease the amount of information a person can process, and lead to short-term memory deficits.
• Recently, there has been emphasis on the use of performance-enhancing psychological skills (PEPS) to allow providers to think clearly, maintain situational awareness, recall important information, and perform skills efficiently.
• A recent article highlights 4 key elements of an EM model for PEPS that can be used to improve performance in resuscitations.
  • Breathe - consider tactical breathing
  • Talk - positive instructional or motivational self-talk
  • See - visualize the steps of a procedure before actually performing it
  • Focus - use a trigger word as a prompt to shift attention to a prioritized task

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PCL injuries can sometimes have involvement of the posterolateral corner (PLC)

The dial test can be used to diagnose posterior lateral instability and help differentiate it from isolated PCL injuries

The dial test involves comparing the amount of external rotation of the lower leg at the knee while the knees are in 30° and in 90° of knee flexion.

https://www.youtube.com/watch?v=rnk62Y-nDSQ

An isolated injury to the posterolateral corner will result in more than 10° of external rotation in the injured knee that is present at 30° but not at 90° of knee flexion.

http://www.kneejointsurgery.com/wp-content/uploads/2015/06/DIAL-TEST.jpg

http://www.kneejointsurgery.com/wp-content/uploads/2015/06/DIAL-TEST-90.jpg

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Ventricular shunt (VP) malfunction can be severe and life-threatening and evaluation has typically included a dry CT brain and a shunt series which includes multiple x-rays of the skull, neck, chest and abdomen.  The goal of this study was to decrease the amount of radiation used in the evaluation of these patients since these patients will likely present many times over their lifetime.  Several institutions have more towards a rapid cranial MRI, however, this modality may not be readily available.

This multidisciplinary team decreased the CT scan radiation dose from 250mA (the reference mA in the pediatric protocol at this institution) to 150 mA which allows for a balance between reducing radiation exposure and adequate visualization of the ventricular system.  They also added single view chest and abdominal x-rays.

The authors found that after implementing this new protocol, there was a reduction in CT radiation doses and number of x-rays ordered with no change in the return rate.

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Takeaways

Vaginal douching is a common and potentially dangerous practice. Women engage in this practice predominately for personal hygiene reasons but also with the false belief it will prevent or treat infections and for contraception. Numerous public health agencies and medical societies discourage douching as it has been associated with many adverse outcomes including pelvic inflammatory disease, bacterial vaginosis, cervical cancer, low birth weight, preterm birth, human immunodeficiency virus transmission, sexually transmitted diseases, ectopic pregnancy, recurrent vulvovaginal candidiasis, and infertility.

An increasing fad is the use of intravaginal detox products. Claiming to enhance female health by removing toxins, these mesh cloth-covered balls containing herbs such as mothersworth, osthol, angelica, borneol, and rhizoma, not FDA-approved, are inserted into the vagina for 3 days. Clinical experience demonstrates these products decompose into numerous pieces which become scattered retained intravaginal foreign bodies, cause mucosal irritation, and thereotically could serve as a nidus for serious infections.

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Takeaways

When surveyed, half of general medicine patients interviewed stated that they would prefer to have a loved one present if they were to develop cardiac arrest and require CPR. So far, studies have demonstrated that…

Allowing family presence during CPR is associated with the following benefits to family members:

• Decreased rates of PTSD-related symptoms
• Decreased scores on anxiety and depression scales
• Decreased incidence of complicated grief
• Decreased incidence of family member regret (at having been present vs absent during CPR)

And is NOT associated with a difference in:

• Survival rate
• Duration of resuscitation efforts
• Type or dose of administered medications
• Number of shocks delivered
• Emotional stress level of medical providers
• Occurrence of medicolegal conflict

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Takeaways

Take Home Points:

1. A radial head subluxation that is common in 1-3 year olds
2. Often secondary to a longitudinal traction on an extended arm
3. With a classic story radiographs are not required
4. The hyperpronation technique has been show to be more effective and less painful in reducing it

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Hydrogen peroxide (H2O2) is a common household liquid that is used for wound irrigation/antiseptic and cosmetic purposes. The concentration of household product is 3% to 5% and is considered to be relatively safe except in large volume ingestion.

High-concentration H2O2 (>10%) is commercially available as “food grade” (35%) that is diluted for household use or for alternative medicine therapy (i.e. hyperoxygenation).

Ingestion of high-concentration of H2O2 can result in caustic injury as well as ischemic injury from gas embolism.

Ingestion of 1 mL of 3% H2O2 produces 10 mL of O2 gas while 1 mL of 35% H2O2 produces 115 mL of O2 gas.

Common symptoms/findings of H2O2 ingestions includes:

• Nausea/vomiting
• Abdominal pain due to gas in portal venous system
• Caustic injury of GI track (ingestion of > 10% H2O2)
• Arterialization of O2 gas result in end-organ injury (e.g. CVA)

A retrospective review of  >10% H2O2 ingestion from National Poison Data System showed:

• 13.9% developed gas embolic event
• 6.8% experienced permanent disability, including 5 deaths.

Management

• Minor symptoms: primary supportive
• CT ABD/Pelvis should be considerd if abdominal pain is present
• If significant gas is present in portal vein or evidence of end-organ injury (i.e. CVA), HBO therapy is recommended (limited evidence).
• Endoscopy should be considered in concentrated H2O2 ingestion to evaluate for caustic injury.

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Question

50 YOF with acute onset of worst headache of life associated with nausea and vomiting.  Patient is somnolent, will rouse to noxious stimuli and complains of a headache as well as decreased vision.

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