UMEM Educational Pearls

Peri-Intubation Cardiac Arrest

  • Endotracheal intubation is a high-risk procedure, especially in the critically ill patient.
  • The incidence of peri-intubation cardiac arrest ranges from 2% to 5%, and is associated with significant increases in morbidity and mortality.
  • Authors of a recent retrospective analysis across 64 French ICUs sought to determine risk factors for cardiac arrest during ICU intubation.
  • Among 1,847 intubations, the main predictors of cardiac arrest during intubation were:
    • Pre-intubation arterial hypotension (SBP < 90 mm Hg) (OR 3.4)
    • Pre-intubation hypoxemia (OR 3.99)
    • Absence of preoxygenation (OR 3.58)
    • Obesity (OR 2)
    • Age > 75 years of age (OR 2.25)
  • Take Home Point
    • Pay close attention to these risk factors and "resuscitate before you intubate".

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Fluid overload (defined in this study as (fluid input-output)/weight)) is associated with longer hospital stays, longer treatment duration and oxygen use.

Bottom line: Treat dehydration appropriately but try not to over resuscitate the asthmatic.  Further studies are needed before definitive recommendations are made.


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Category: Neurology

Title: Prehospital Stroke Scales for Large Vessel Occlusion

Keywords: stroke, prehospital, large vessel occlusion, NIHSS, RACE, LAMS, VAN (PubMed Search)

Posted: 3/14/2018 by WanTsu Wendy Chang, MD (Updated: 6/18/2018)
Click here to contact WanTsu Wendy Chang, MD


  • A recent systematic review evaluated the diagnostic accuracy of 19 prehospital stroke scales.
  • Arm motor strength is the most frequently evaluated item by the scales (15/19), followed by gaze (13/19) and language (13/19).
  • Only 4 scales (RACE, LAMS, VAN, sNIHSS-EMS) were performed by paramedics in their original studies.
  • The NIHSS, LAMS, and VAN appear to have better results in predicting large vessel occlusion.
  • The presence of hemineglect, a sign of cortical involvement, improved the accuracy of the scale.

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Category: Orthopedics

Title: Pectoralis Major Rupture

Keywords: Shoulder pain, muscle injury (PubMed Search)

Posted: 3/10/2018 by Brian Corwell, MD (Updated: 6/18/2018)
Click here to contact Brian Corwell, MD

Pectoralis Major Rupture


Most commonly seen in male weightlifters

Usually occurs as a tendon avulsion

Incidence is increasing

Hx: Sudden, sharp, tearing sensation with pain and weakness with arm movement

PE: Palpable defect and deformity of anterior axillary fold. Bruising and swelling.

               Deformity may not be obvious with arm by side and relaxed

Testing: Weakness with ADDuction and internal rotation


Treatment:  Operative treatment has better outcomes but depends on patient subgroups

Nonoperative treatment generally indicated for partial ruptures and tears in the body of the pec and muscle tendon junction

               Sling, ice and pain control.

Operative treatment generally for high demand patients (athletes) and bony avulsion injuries


Signs and symptoms of acute cyanide poisoning are not well characterized due to its rare occurrence.  Commonly mentioned characteristics of bitter almond odor and cherry red skin have poor clinical utility.

Recently published review of 65 articles (102 patients) showed that most patients experienced following signs and symptoms:

  1. Unresponsive: 78%
  2. Respiratory failure: 73%
  3. Hypotension: 54%
  4. Cardiac arrest: 20%
  5. Seizure: 20%
  6. Cyanosis: 15%
  7. Odor: 15%
  8. Cherry red skin: 11%

There is no clear toxidrome for cyanide poisoning.

In a poisoned patient, health care providers should consider cyanide in their differential diagnosis in the presence of severe metabolic and lactic acidosis (lactic acid > 8 in isolated cyanide poisoning or > 10 in smoke/fire victim).

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Contrary to a popularly held belief that one can estimate the age of a bruise by its color, present day research found that the color of a bruise at the time of its initial appearance is unpredictable. It is also affected by medications.
Take Home: Do not assumptions about the age of the bruise based on the color.

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Category: Pharmacology & Therapeutics

Title: Fosfomycin for UTIs

Keywords: Fosfomycin, urinary tract infection, cystitis (PubMed Search)

Posted: 3/3/2018 by Wesley Oliver
Click here to contact Wesley Oliver

Fosfomycin is an antibiotic infrequently used for the treatment of urinary tract infections (UTIs). It has a broad spectrum of activity that covers both gram-positive (MRSA, VRE) and gram-negative bacteria (Pseudomonas, ESBL, and carbapenem-resistant Enterobacteriaceae), which is useful in the treatment of multidrug-resistant bacteria. 

Fosfomycin is FDA approved for the treatment of uncomplicated UTIs in women due to susceptible strains of Escherichia coli and Enterococcus faecalis (3g oral as a single dose). Data has also demonstrated that it can be used for complicated UTIs; however, dosing is different in this population (3 g oral every 2-3 days for 3 doses).  Fosfomycin is not recommended for pyelonephritis.

The broad spectrum of activity, in addition to only needing a single dose in most cases, makes fosfomycin an attractive option; however, it should be reserved for use in certain circumstances.  Fosfomycin should not be considered as a first-line option.  It is also more expensive than other medications (~$100/dose) and in countries with high rates of utilization bacteria are developing resistance to fosfomycin.  In addition, most outpatient pharmacies do not keep this medication in stock.

Take-Home Point:

Fosfomycin should be reserved for multidrug-resistant UTIs in which other first-line options have been exhausted.

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A leading cause of cardiac arrest in patients 40 years and younger is due to drug poisoning.  Adverse cardiovascular events (ACVE) such as myocardial injury (by biomarker or ECG), shock (hypotension or hypoperfusion requiring vasopressors), ventricular dysrhythmias (ventricular tachycardia/fibrillation, torsade de pointes), and cardiac arrest (loss of pulse requiring CPR) are responsible for the largest proportion of morbidity and mortality overdose emergencies. Clinical predictors of adverse cardiovascular events in drug overdose in recent studies include:

  • QTc prolongation on presentation ECG ( > 500 msec )
  • Prior history of either coronary artery disease or congestive heart failure
  • Metabolic acidosis (elevated serum lactate)


Bottom line:

Obtain ECG and perform continuous telemetry monitoring in overdose patients with above risk factors. Patients with two or more risk factors have extremely high risk of in-hospital adverse cardiovascular events and intensive care setting should be considered.



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Category: Neurology

Title: Headache in the Bodybuilder

Keywords: headache, steroids, bleed (PubMed Search)

Posted: 2/28/2018 by Danya Khoujah, MBBS
Click here to contact Danya Khoujah, MBBS

Benign headaches are common in bodybuilders. However, several less benign headaches are worth noting:

  • Low cerebrospinal fluid (CSF) pressure headache: caused by a small dural tear mostly at the thoracic level. Similar to postdural headache. Treated by recumbency, and blood patches if recalcitrant.
  • Subarachnoid hemorrhage (SAH)
  • Spontaneous intracranial hemorrhage
  • Ischemic stroke
  • Dural sinus thrombosis

All except the first two are exclusively reported in patients on anabolic steroids, growth hormone, and/or “energy” supplements. Make sure to ask your patient about these risk factors.


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Category: Critical Care

Title: Empiric Antifungal Therapy in Septic Shock

Keywords: ICU, fungal infection, septic shock, antifungal therapy, empiric (PubMed Search)

Posted: 2/27/2018 by Kami Hu, MD
Click here to contact Kami Hu, MD


Which septic patients should receive empiric antifungal therapy?

Patients with fungemia only make up about 5% of patients presenting with septic shock, but invasive fungal infections are associated with increased hospital mortality (40-50%), prolonged ICU and hospital length of stay, and increased costs of care.1

The EMPIRICUS trial showed no mortality benefit to empiric antifungals for all, even patients with candidal colonization and recent exposure to antibiotics.2

Bottom Line

Therapy should always be tailored to the specific patient, but providers should strongly consider admininistering empiric echinocandin (micafungin, caspofungin) over fluconazole in patients with severe sepsis/septic shock and:

  • Immunosuppression (chronic steroids, neutropenia, organ transplant)
  • Prolonged central venous catheters
  • TPN
  • Yeast colonization
  • Severe pancreatitis
  • Recent abdominal surgeries or procedures (perforation repairs, resections, etc.) or concern for impaired gut integrity

*Especially consider addition of antifungal in patients who do not show improvements after initial management with IVF and broad spectrum antibiotics in the ED.*

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Category: Orthopedics

Title: New blood test for concussion

Keywords: Mild traumatic brain injury, concussion (PubMed Search)

Posted: 2/25/2018 by Brian Corwell, MD (Updated: 6/18/2018)
Click here to contact Brian Corwell, MD

The search for an objective reliable test for mild traumatic brain injury found an early promising result last week.

               May be arriving in your hospital in the near future.

               A handheld sideline version is sure to follow

The FDA approved the first blood test for concussion/mild TBI

               Called the Banyan BTI (Brain Trauma Indicator)

This test measures 2 neural protein biomarkers released into the blood following mild TBI

The FDA approved this test within 6 months after reviewing data on just under 2,000 blood samples.

               They concluded the Banyan BTI can predict the absence of cranial CT lesions with an accuracy greater than 99% and may reduce imaging in up to a 1/3rd

Be optimistic but consider the small sample size and remember that this test looks for biomarkers and may miss subtle cases where proteins didn’t leak. This test is NOT ready to be used for return to play decisions. It takes 3 to 4 hours to result and costs about $150. Other biomarkers are being investigated and may prove to be better


Category: Toxicology

Title: Toxin-induced nystagmus

Keywords: nystagmus, toxic (PubMed Search)

Posted: 2/22/2018 by Hong Kim, MD, MPH
Click here to contact Hong Kim, MD, MPH

Abnormal ocular movement (e.g. nystagmus) can often be observed in select CNS pathology.

Certain drugs/toxin overdose can also induce nystagmus.

  • Anti-epileptics: carbamazepine, lamotrigine, topiramate, phenytoin
  • Ethanol
  • Ketamine, phencyclidine (PCP), dextromethorphan – vertical or rotary nystagmus
  • Serotonergic syndrome/5-HT agonists – opsoclonus
  • Monoamine oxidase inhibitors – ping-pong nystagmus
  • Lithium
  • Scorpion envenomation 

In an "unknown" intoxication, physical exam findings such as nystagmus may help narrow the identity of the suspected ingestion/overdose.

-Nonischemic cardiomyopathy, classically seen in post-menopausal women preceded by an emotional or physical stressor

-Named for characteristic appearance on echocardiography and ventriculography with apical ballooning and contraction of the basilar segments of the LV – looks like a Japanese octopus trap or “takotsubo" (pot with  narrow neck and round bottom)

-Clinical presentation usually similar to ACS with chest pain, dyspnea, syncope, and EKG changes not easily distinguished from ischemia (ST elevations – 43.7%, ST depressions, TW inversions, repol abnormalities) and elevation in cardiac biomarkers (though peak is typically much lower than in true ACS)


** Diagnosis of exclusion – only after normal (or near-normal) coronary angiography **


-Care is supportive and prognosis is excellent with full and early recovery in almost all patients (majority have normalization of LVEF within 1 week)

-Supportive care may include inotropes, vasopressors, IABP, and/or VA ECMO in profound cardiogenic shock


** LVOT Obstruction **

-occurs in 10-25% of patients with Takotsubo’s cardiomyopathy

-LV mid and apical hypokinesis with associated hypercontractility of basal segments of the LV predisposes to LV outflow tract obstruction

-Important to recognize as it is managed differently:

            -may be worsened by hypovolemia, inotropes, and/or systemic vasodilatation

            -mainstay of treatment is avoidance of the above triggers/exacerbating factors while increasing afterload

                    *phenylephrine is agent of choice +/- beta blockade 



Take Home Points:

***Diagnosis of exclusion!!! Presentation very similar to ACS and ACS MUST be ruled out

* Treatment is supportive and similar to usual care for cardiogenic shock. Can be severe and require mechanical circulatory support!

*10-25% have LVOT obstruction. Manage with phenylephrine +/- beta blockade

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75 y/o M is brought in by EMS after he fell off the light rail and hit his head. In the ED he is A&Ox3, and is asking for a urinal. Two minutes later the tech comes running to show you the following:

What is the cause of this patients Jolly Rancher Green Apple looking urine sample? 

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Category: Pediatrics

Title: What is the diagnosis?

Keywords: foreign body, choking (PubMed Search)

Posted: 2/16/2018 by Jenny Guyther, MD
Click here to contact Jenny Guyther, MD


Patient: 11 month old with trouble breathing and color change after a family member sprayed air freshener.  Symptoms have since resolved.

What are you concerned about in the attached xrays?

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11_mo_lung_FB_word.docx (408 Kb)

Category: Toxicology

Title: Bupropion Cardiotoxicity

Keywords: Cardiotoxicity, Bupropion, Ventricular dysrhythmia (PubMed Search)

Posted: 2/15/2018 by Kathy Prybys, DO
Click here to contact Kathy Prybys, DO

Bupropion (Wellbutrin, Zyban) is unique monocyclic antidepressant and smoking cessation agent that is structurally similar to amphetamines.  Bupropion blocks dopamine and norepinephrine reuptake and antagonizes acetylcholine at nicotinic receptors.

  • One of the most common causes of drug-induced seizures.
  • Sinus tachycardia is the most frequently seen cardiac effects with overdose.
  • QTc prolongation and ventricular dysrhythmias can occur in severe overdose. New evidence supports this is not related to cardiac sodium channel block but likely due to blockade of the delayed rectifying (ikr) potassium channel and gap junction inhibition in the myocardium simulating effects class IA effect.


Bottom line:

Bupropion is a common cause of drug induced seizures but in severe overdose can also cause prolonged QTc and wide complex ventricular dysrhythmia that may be responsive to sodium bicarbonate. All patients with an overdose of bupropion should have an ECG performed and cardiac monitoring to watch for conduction delays and life-threatening arrhythmias.




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Category: Neurology

Title: Occipital Nerve Block for Migraine?

Keywords: occipital nerve block, migraine, headache (PubMed Search)

Posted: 2/14/2018 by WanTsu Wendy Chang, MD (Emailed: 2/15/2018) (Updated: 2/15/2018)
Click here to contact WanTsu Wendy Chang, MD

  • Greater occipital nerve (GON) block with local anesthetics is an alternate treatment option for headaches.
  • Zhang et al. conducted a systematic review and meta-analysis of 7 randomized controlled trials assessing the efficacy of GON block for migraine.
  • Pooled outcome suggests that GON block: 
    • Reduces pain intensity (mean difference -1.24 [-1.98, -0.49], p=0.001)
    • Decreases analgesia medication consumption (mean difference -1.10 [-2.07, -0.14], p=0.02)
    • Has no significant impact on headache duration (mean difference -6.96 [-14.09, 0.18], p=0.06)

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Category: Orthopedics

Title: Femoral neck stress fracture

Keywords: Hip pain, athletes (PubMed Search)

Posted: 2/10/2018 by Brian Corwell, MD (Updated: 6/18/2018)
Click here to contact Brian Corwell, MD

Femoral neck stress fractures


Represents 5% of all stress fractures

Usually due to repetitive abductor muscle contraction

As with all stress fractures can occur in 2 types

1)      Insufficiency type (normal physiologic stress on abnormal bone)

2)      Fatigue type (abnormal/excessive physiologic stress on normal bone)

2 locations on interest:

1)      Compression side (inferior femoral neck)

2)      Tension side (superior femoral neck)

History: Insidious onset of groin or lateral hip pain associated with weight bearing

Exam: Antalgic gait, pain with hip log roll and with FABER (hip flexion, Abduction and external rotation test)


Compression side: reduced weight bearing and activity modification

Tension side:  Non weight bearing (due to high risk of progression to displacement with limited weight bearing) AND surgical consultation for elective pinning to prevent displacement. If displaced, will require ORIF

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Category: Pediatrics

Title: Mucositis... when the shoe doesn't fit (submitted by Alexis Salerno, MD)

Keywords: Kawasaki's disease, SJS, TEN, dermatitis (PubMed Search)

Posted: 2/9/2018 by Mimi Lu, MD
Click here to contact Mimi Lu, MD


Case:  5 year old presents to the ED with 2 weeks of fever. She has extensive cracked, bleeding lips and a rash on her hands and feet. She was recently diagnosed with “walking pneumonia” and hand, foot and mouth disease this week. Her pediatrician sent her in for further workup after she was found to have an elevated CRP on outpatient labs. A similar picture appears in the link below:

What's the diagnosis?


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Hyperoxia and the Post-Arrest Patient

  • Current post-arrest guideilnes recommend titrating supplemental O2 to avoid hypoxia and limit exposure to hyperoxia.
  • Importantly, these recommendations are based primarily on retrospective studies that have used ABG values within the first 24 hours following ROSC.
  • The latest study to evaluate the impact of hyperoxia following cardiac arrest was just published in Circulation
  • This study is a prospective, cohort study that evaluated the association between early hyperoxia and poor neurologic outcome in adults following cardiac arrest. (ABGs were obtained at 1 hour and 6 hours following ROSC)
  • Of 280 patients, 38% were exposed to early hyperoxia (defined as a PaO2 > 300 mm Hg)
  • Take Home Points
    • Early hyperoxia was found to be an independent predictor of poor neurologic outcome at hospital discharge.
    • One hour longer duration of hyperoxia was associated with a 3% increase in the risk of poor neurologic outcome
    • SaO2 could not reliably exclude the presence of hyperoxia.

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