UMEM Educational Pearls

Category: International EM

Title: Should you order labs on that routine psychiatric patient?

Keywords: Mental health, routine laboratory test, acute psychiatric patient (PubMed Search)

Posted: 8/2/2017 by Jon Mark Hirshon, MD, MPH
Click here to contact Jon Mark Hirshon, MD, MPH

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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Category: Critical Care

Title: APRV Effects on RV Function

Keywords: RV dysfunction, APRV, echo, ultrasound (PubMed Search)

Posted: 8/1/2017 by Daniel Haase, MD
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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

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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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Category: Toxicology

Title: Importance of hemodialysis in intubated salicylate poisoned patients

Keywords: salicylate poisoning, endotracheal intubation, hemodialysis (PubMed Search)

Posted: 7/27/2017 by Hong Kim, MD, MPH
Click here to contact Hong Kim, MD, MPH

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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Category: Pediatrics

Title: Reducing radiation exposure in evaluation of ventricular shunt malfunctions in children

Keywords: CT scans, radiation exposure, pediatrics (PubMed Search)

Posted: 7/21/2017 by Jenny Guyther, MD (Updated: 11/20/2017)
Click here to contact Jenny Guyther, MD

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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Category: Toxicology

Title: Vaginal Detox?

Keywords: Vaginal pearls, intravaginal foreign bodies (PubMed Search)

Posted: 7/20/2017 by Kathy Prybys, DO (Emailed: 7/21/2017) (Updated: 7/21/2017)
Click here to contact Kathy Prybys, DO

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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Category: Critical Care

Title: Benefits of Family Presence During CPR

Keywords: Resuscitation, CPR, family, policy (PubMed Search)

Posted: 7/17/2017 by Kami Hu, MD
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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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Category: Orthopedics

Title: Nursemaid Elbow

Keywords: nursemaid, elbow (PubMed Search)

Posted: 7/15/2017 by Michael Bond, MD
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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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Category: Neurology

Title: What is the cause of this patient's decreased vision?

Keywords: Terson syndrome, vitreous hemorrhage, intraocular hemorrhage, subarachnoid hemorrhage (PubMed Search)

Posted: 7/12/2017 by WanTsu Wendy Chang, MD
Click here to contact WanTsu Wendy Chang, MD

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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Category: Orthopedics

Title: Legg Calve Perthes Disease

Keywords: Hip, pediatrics, arthritis (PubMed Search)

Posted: 7/9/2017 by Brian Corwell, MD
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Question

Idiopathic osteonecrosis of the femoral head

Children as young as 2 or as old as 12 but generally 4 to 8 (worse in older children)

Fare better than adults with osteonecrosis of femoral head

1 in 10,000

4-5x more common in males, much less common ini African Americans

Unilateral femoral head involvement 90% of the time (Bilateral 10% of the time)

Long term consequences are deformity and arthritis

Typical presentation: Subacute limping for weeks (Painless)

As activity worsens limp, it is maximal at the end of the day (Intermittent)

As in adults with hip pathology, IF pain is reported, it is located at the upper anterior thigh and groin

On examination, look for restriction in range of motion of the hip (compare with contralateral side)

May only present with mild to moderate decreased range of motion of the hip

            30 versus 60 degrees for example

             ABduct both legs with pelvis in neutral OR Place one hand on contralateral pelvis and ABduct affected leg with other hand.

 

 

 

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Serious outcomes after overdose or nonintentional exposures to medications used to treat depression have risen dramatically over the past 15 years. Morbidity and mortality associated with drugs used to treat depression were studied utilizing the National Poison Data System from 2000-2014. Tricyclic and monoamine oxidase inhibitor medications were associated with the highest morbidity and mortality. Newer agents such as Lithium, venlafaxine, bupropion, quetiapine, olanzapine, ziprasidone, valproic acid, carbamazepine, and citalopram were also associated with higher mortality indices.

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Category: International EM

Title: In the Time of Cholera

Keywords: Cholera, conflict, children (PubMed Search)

Posted: 7/5/2017 by Jon Mark Hirshon, MD, MPH (Updated: 11/20/2017)
Click here to contact Jon Mark Hirshon, MD, MPH

Cholera is an acute diarrheal disease that can kill within hours if left untreated.

Rising cholera, diarrhea and malnutrition is a deadly combination in war torn countries, such as Yemen, South Sudan, Somalia and Sudan, especially for children.

Yemen currently has the worst outbreak globally, with over 260,000 suspected cases and over 1,600 deaths. In Yemen:

o   Half the suspected cases are children

o   A quarter of the deaths are among children

 

Bottom Line:

Cholera remains a major cause of morbidity and mortality globally, especially in areas of conflict.

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When you are working up an elderly patient for trauma  look for patterns such as circumferential bruising on the wrists that have the pattern of fingers the same way you would look at the injuries of a child. Remember that the person who is sitting next to them is frequently the person that is abusing them. Therefore, it is important to interview the patient alone. 

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Category: Pharmacology & Therapeutics

Title: Levofloxacin dosing for CAP

Keywords: Levofloxacin, duration, dose, CAP, pneumonia (PubMed Search)

Posted: 7/1/2017 by Jill Logan (Updated: 11/20/2017)
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Takeaways

When you look up dosing for levofloxacin for community acquired pneumonia (CAP), you will find that both of the following options are approved:

  • Levofloxacin 500 mg IV/PO daily x 7-14 days
  • Levofloxacin 750 mg IV/PO daily x 5 days

This is based on a multicenter, randomized, double-blind, active treatment trial comparing these two regimens in CAP (mild to severe). This non-inferiority trial shows that the 750 mg dose of levofloxacin for 5 days is "at least as effective and well tolerated" as the 500 mg dose of levofloxacin for 10 days.

So why should you choose the 750 mg daily x 5 day regimen?

  • Higher doses maximize the concentration-dependent pharmacokinetic profile of the drug
  • Higher doses and shorter duration may be associated with less drug resistance
  • Patients subjectively report feeling better at day 3 with the higher dose regimen

As alway with levofloxacin, don't forget to renally dose adjust subsequent doses when writting a script or scheduled inpatient order for patients with reduced creatinine clearance! 

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Category: Toxicology

Title: Black Widow Bite

Keywords: Lactrodectus (PubMed Search)

Posted: 6/29/2017 by Kathy Prybys, DO (Emailed: 6/30/2017) (Updated: 6/30/2017)
Click here to contact Kathy Prybys, DO

 Black widow  spiders belong to the genus Latro dectus which include 31 species of widow spiders found throughout world. Approximately 1500-2500 black widow bites are reported to American poison control centers annually. A black widow can be identified by their hourglass pattern (red or orange) on the ventral aspect of their shiny globular abdomen. Fortunately, envenomation is rare but when it does occur it causes severe pain, muscle cramping, abdominal (may mimic acute abdomen) often refractory to traditional analgesics and antivenom (Antivenin Latrodectus mactans) is available and effective . Alpha-latrotoxin is the potent toxin causing presynaptic cation channels to open (calcium) and release of neurotransmitters such acetycholine. The neurological signs and symptoms caused by predominantly autonomic and include tachycardia and hypertension. The antivenom is equine based and infused over 20-30 minutes with pain relief in 20 minutes.

 

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Attachments

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Category: Neurology

Title: Autoimmune Neurological Disease

Keywords: autoimmune, cancer, encephalopathy (PubMed Search)

Posted: 6/28/2017 by Danya Khoujah, MBBS
Click here to contact Danya Khoujah, MBBS

One of the differentials of a subacute neurological deficit (usually with a fluctuating course) is autoimmune neurologic disorders. This can encompass anything from neuropathic symptoms, to cerebellar pathology, to encephalitis-like picture. A personal or family history of autoimmune disease or malignancy should heighten suspicion, and the CSF is likely an inflammatory CSF profile as well (pleocytosis). Neural autoantibodies confirm the diagnosis, and are usually performed in both the serum and the CSF. Most laboratories perform a global screen for a number of potential antibodies that fit the concerning clinical picture, rather than one or two tests.
In addition, autoimmune CNS pathology is concerning for a paraneoplastic syndrome e.g. teratoma, lymphoma or small cell lung cancer.

Take Home Message: If suspecting an autoimmune pathology due to the risk factors and subacute nature of the disease, obtain some extra CSF to run the necessary tests after consulting with neurology. 

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Category: Critical Care

Title: Ventilation During Cardiopulmonary Resuscitation

Keywords: CPR, ventilation, respiratory rate, PaCO2 (PubMed Search)

Posted: 6/27/2017 by Mike Winters, MD
Click here to contact Mike Winters, MD

Ventilation During Cardiopulmonary Resuscitation  

  • Cardiopulmonary resuscitations are often highly stressful and chaotic situations.  As a result, it is no surprise that ventilation rates can be as high as 60 breaths per minute.  
  • Hyperventilation during cardiopulmonary resuscitation can increase intrathoracic pressure, impair venous return, decrease coronary perfusion pressure, and ultimately decrease survival.
  • It is imperative that the team leader pay close attention to ventilation and ensure that approximately 8 to 10 breaths per minute are delivered.
  • Once ROSC is achieved, the respiratory rate should be adjusted to maintain a PaCO2 between 40 and 45 mm Hg.  

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