UMEM Educational Pearls

Category: Neurology

Title: Cerebral Venous Thrombosis (CVT)

Keywords: headache, seizure, stroke, neurological deficit, thrombogenic (PubMed Search)

Posted: 12/27/2017 by Danya Khoujah, MBBS (Updated: 6/22/2018)
Click here to contact Danya Khoujah, MBBS

Cerebral venous thrombosis is a rare (but dangerous) cause of headaches and strokes in patients below the age of 50. It includes thrombosis of the cerebral veins and major dural sinuses. 
A d-dimer can NOT be used to rule it out, as it would be falsely negative in up to 40% of patients. A dry head CT is completely normal in 30% of patients, with nonspecific changes present in another 30%.

Take home: If you are considering the diagnosis, obtain a CT venography (95% sensitive) and don’t rely on a negative dimer or dry head CT.

 

Show References


Category: Pediatrics

Title: What is the ideal observation time for a patient with croup who has received racemic epinephrine?

Keywords: Croup, epinephrine, discharge, observation (PubMed Search)

Posted: 12/15/2017 by Jenny Guyther, MD (Updated: 6/22/2018)
Click here to contact Jenny Guyther, MD

The peak age for croup is 6 months to 3 years.  The cornerstone of treatment is corticosteroids, traditionally dexamethasone.  With oral administration, the peak onset is 1-2 hours. Steroids shorten the duration of symptoms, reduce the need for nebulized epinephrine and decrease the need for intubation.

Racemic epinephrine has been used for moderate to severe croup and can show an improvement in patient symptoms for up to 120 minutes.  There is little evidence to suggest how long to observe the patient for recurrence of symptoms after racemic epinephrine was given.  Previous studies have suggested both 2 and 4 hour observation.

299 patients were included in this study.  136 patients were observed for 3.1 to 4 hours.  In the 3.1 to 4 hour group, 21 (7%) failed treatment, 19 of those patients required admission and 2 returned within 24 hours.  No patients who were discharged home after 4 hours returned to the emergency department within 24 hours.

Bottom Line: Consider a 4 hour period of observation after giving racemic epinephrine in order to decrease bounce backs.

Show References


Category: Neurology

Title: A New DAWN for Stroke Intervention?

Keywords: DAWN, thrombectomy, mismatch, wake-up, stroke, penumbra (PubMed Search)

Posted: 12/13/2017 by WanTsu Wendy Chang, MD
Click here to contact WanTsu Wendy Chang, MD

Takeaways

  • The DAWN trial was a multicenter, randomized, open-label study comparing endovascular thrombectomy plus standard medical care with standard medical care alone for patients with:
    • Acute stroke symptoms
    • Last known well 6 to 24 hours earlier
    • Evidence of intracranial ICA or proximal MCA occlusion
    • Mismatch between clinical deficit and infarct volume on CTA or MRA
  • The study found that patients receiving thrombectomy plus standard medical care had improved functional independence at 90 days as defined by modified Rankin Scale (mRS) of 0, 1, or 2 (49% vs 13%).
  • The trial was stopped early based on prespecified interim analysis intended with the adaptive trial design.
  • While the two treatment groups were similar, with median NIHSS score of 17, they had small infarct volumes and short time from symptom observation (4.8 vs 5.6 hours) compared to time of patient's last known well (12.2 vs 13.3 hours). 
  • 88% of the patients had unwitnessed stroke onset (including wake-up strokes), thus it is possible that these patients had actual ischemia times closer to 6 hours, thereby reproducing similar results as prior thrombectomy trials.

Bottom Line: The use of neuroimaging to identify an ischemic penumbra that may benefit from thrombectomy may be considered even for patients with time of last known well beyond 6 hours.

Show More In-Depth Information

Show References


Sedating The Critically Ill Patient

  • Sedating critically ill ED patients can be challenging.
  • Excessive sedation is associated with a prolonged duration of mechanical ventilation, ICU LOS, and may increase mortality.
  • Important pearls to consider when managing these patients include:
    • Prioritize pain management first - may reduce the need for sedative medications
    • When possible, target a calm and interactive patient shortly after intubation - consider adding a atypical antipyschotic with propofol or dexmedetomodine
    • Use a validated tool (i.e., RASS) to dose opioids and sedative medications
    • Avoid continuous infusions of benzodiazepines

Show References


Category: Orthopedics

Title: Iselin disease

Keywords: 5th metatarsal, fracture, overuse (PubMed Search)

Posted: 12/9/2017 by Brian Corwell, MD
Click here to contact Brian Corwell, MD

CC: 12yo boy presents with pain to base of 5th metatarsal

 

Osteochondrosis overuse syndromes associated with development of secondary ossification or apophyseal centers

Iselin disease – Osteochondrosis of 5th MT base

Lateral 5th foot pain with weight bearing and activity in early adolescence

Child may limp or walk on inner part of foot

               Adolescents:  Girls >10, Boys >12

               Commonly seen in soccer, basketball, gymnastics and dance

Exam: Tenderness to palpation at proximal 5th MT at peroneal brevis insertion

Area may show edema and redness

Pain with foot inversion and resisted eversion and dorsiflexion

XR: May be normal or show enlargement or fragmentation of epiphysis

Obliquely oriented small bony fleck at 5th MT base. Parallel to long axis of 5th MT. Best seen on oblique view. Unlike fractures which tend to be horizontally oriented.

Treatment: Immobilize for comfort if severe (walking boot) or simple activity modification if mild. Ice and calf muscle stretching.

http://https://images.radiopaedia.org/images/2343487/d3478d2024c845ba0f2fffffd7d51c_big_gallery.jpg


Category: Toxicology

Title: Loperamide Cardiac Toxicity

Keywords: Loperamide, cardiotoxicity, QT prolongation (PubMed Search)

Posted: 12/7/2017 by Kathy Prybys, DO (Emailed: 12/8/2017) (Updated: 12/8/2017)
Click here to contact Kathy Prybys, DO

Takeaways

Loperamide (Imodium) is a common inexpensive over-the counter antidiarrheal agent. It acts peripherally at the mu opioid receptor to slow gastrointestinal motility and has no CNS effects at therapeutic doses due to it's low bioavailability and limited abillity to cross the blood brain barrier dependent on glycoprotein transport. In the past few years, reports of loperamide abuse causing serious cardio toxicity began to appear in the literature. Abused at daily doses of 25-200 mg to get high or and to treat symptoms of withdrawal. (therapeutic dose: 2-4 mg with a maximun of 8mg for OTC and 16mg for prescription). Loperamide has been called the "poor man's methadone".

At large doses, loperamide effects the cardiac sodium, potassium and calcium channels which prolongs the QRS complex  and can lead to ventricular arrhythmias, hypotension, and death. Clinical features includes:

  • QT prolongation
  • QRS widening
  • Ventricular arrythmias
  • Hypotension
  • Syncope
  • CNS depression

 

Take Home Point:

Consider loperamide as a possible cause of unexplained cardiac events including QT interval prolongation, QRS widening, Torsades de Pointes, ventricular arrhythmias, syncope, and cardiac arrest. Intravenouse sodium bicarbonate should be utilized to overcome blockade and may temporize cardiotoxic events. Supportive measures necessary may include defibrillation, magnesium, lidocaine, isoproternol, pacing, and extracorporeal life support.

 

 

Show More In-Depth Information

Show References


Category: Infectious Disease

Title: Risk Factors for Community Associated C. difficile Infection

Keywords: c. difficile, antibiotic (PubMed Search)

Posted: 12/2/2017 by Ashley Martinelli (Emailed: 12/6/2017) (Updated: 12/6/2017)
Click here to contact Ashley Martinelli

Community-associated Clostridium difficile infection (CA-CDI) represents 41% of all CDI cases annually.  The association of specific outpatient exposures was assessed in a case control study by Guh, et al. They reviewed the CDC’s active surveillance reporting from 10 states through the Emerging Infections Program (Maryland participates).

Cases: ≥18, + C. difficile stool specimen collected as an outpatient or within 3 days of hospitalization, with no overnight stay in a health care facility in the prior 12 weeks, and no prior CDI diagnosis

Controls: matched 1:1 for age and sex within the same surveillance catchment area as the case patient on the date of the collection specimen. Exclusion criteria: prior diagnosis of CDI, diarrheal illness, overnight stay in health care facility in the prior 12 weeks

Data Collection: telephone interview, standardized questionnaire or comorbidities, medication use, outpatient health care visits, household and dietary exposures in the prior 12 weeks

Results: 452 participants (226 pairs), over 50% were ≥ 60 years of age, 70.4% female, and 29% were hospitalized within 7 days of diagnosis, no patients developed toxic megacolon or required colectomy.

Cases had more health care exposures, including the emergency department (11.2% vs 1.4% p <0.0001), urgent care (9.9% vs 1.8%, p=0.0003). In addition, cases also reported higher antibiotic exposures (62.2% vs 10.3%, p<0.0001) with statistically significant higher exposure to cephalosporins, clindamycin, fluoroquinolones, metronidazole, and beta-lactam and/or beta-lactamase inhibitor combination. The most common antibiotic indications were ear or sinus infections, URI, SSTI, dental procedure, and UTI. No differences were found in household or dietary exposures.

Take-home point: This study highlighted the risk for CA-CDI infection for patients presenting to an ED and reiterates that exposures to fluoroquinolones, cephalosporins, beta-lactam and/or beta-lactamase inhibitor combinations, and clindamycin significantly increases the risk of CA-CDI infection. Reducing unnecessary outpatient antibiotic prescribing may prevent further CA-CDI. 36% of case patients did not have any antibiotic or outpatient health care exposure; therefore, additional risk factors may exist.

Show References


Category: Critical Care

Title: ECMO in HIV/AIDS Patients

Posted: 12/5/2017 by Ashley Menne, MD (Updated: 6/22/2018)
Click here to contact Ashley Menne, MD

Severe acute respiratory failure among patients with PCP pneumonia, especially among those newly diagnosed with AIDS, remains a disease of high morbidity and mortality. Among those requiring mechanical ventilator support, the mortality rate has been reported between 50-70%.

According to ELSO guidelines, pharmacologic immunosuppression (specifically neurtrophil <400/mL) is a relative contraindication. Furthermore, a status predicting poor outcome despite ECMO should also be considered a relative contraindication.

That said, there are several case reports now of successful use of ECMO in AIDS patients, particularly those suffering with PCP pneumonia.

In a case report and literature review published in BMJ in Aug 2017, 11 cases of ECMO (including 1 VA) in AIDS patients were described.

  • 7 survived to hospital discharge (including 1 VA)
  • 2 survived to decannulation, but ultimately died in hospital
  • 2 died on ECMO
  • Length of ECMO runs in survivors varied between 4 days (VA) to 31 days

 

Bottom Line: HIV/AIDS is not an absolute contraindication to VV ECMO therapy in ARDS and may be particularly useful in the treatment of severe PCP pneumonia. Initiation of ECMO in this patient population should be considered on an individual case by case basis. 

Show References


Category: Critical Care

Title: IVF Resuscitation in Obese Septic Patients: Not one-weight-fits-all?

Keywords: sepsis, resuscitation, obesity, IV fluids, bolus (PubMed Search)

Posted: 12/5/2017 by Kami Hu, MD
Click here to contact Kami Hu, MD

Background:

We are all familiar with the Surviving Sepsis Campaign recommendation (& CMS core measure) for an initial 30ml/kg bolus of IV crystalloid within the first 3 hours for our patients with septic shock. There is minimal data, however, on how much IVF we should be giving our patients with BMIs ≥30.

 

A recent study in obese patients with septic shock retrospectively stratified the total fluids administered at 3 hours into 3 different weight categories, to categorize patients as having received 30mL per kg of ___ body weight, whether actual (ABW), adjusted (AjdBW), or ideal (IBW**).

AdjBW = (ABW – IBW) *40% + IBW

They found:

  • Most patients received fluids based on actual body weight, BUT
  • Patients at highest BMIs received ABW fluids less often
  • 30ml/kg dosing according to adjusted body weight was associated with improved mortality compared to IVF per actual or ideal body weight.

 

Bottom Line:

  • If the 30ml/kg IVF bolus seems clinically appropriate for your obese patient, consider administering according to Adjusted Body Weight first.
  • As always, reevaluate your septic shock patients frequently to determine if additional fluids are necessary, and go to vasopressors early if they are not fluid responsive.

 

**IBW calculated using Devine’s formula for men and women:

  • Males:  IBW = 50 + 2.3*(# inches over 5 feet)
  • Females: IBW = 45.5 + 2.3*(# inches over 5 feet)

Show References


Asymptomatic bacteriuria is common and increases with age, with an incidence of up to 50% in women over the age of 70.  Asymptomatic bacteriuria does not carry an associated high morbidity or mortality if left untreated; it is usually transient and resolves spontaneously.  In order to decrease polypharmacy and possible drug interactions in our elderly patients, they should only be diagnosed with and treated for a UTI if they have laboratory evidence of a UTI (bacteriuria and pyuria) and have two of the following:

·      Fever

·      Worsened urinary urgency or frequency

·      Acute dysuria

·      Suprapubic tenderness

·      Costovertebral angle tenderness

Show References


Question

 

Different chemical, food or pharmaceutical agent exposure can change the color of the urine.

What could cause this patient's urine to turn green?

Show Answer


Attachments

IMG_4194.JPG (2,012 Kb)


Category: Orthopedics

Title: Tibial shaft stress fractures

Keywords: Stress fracture, runner, non union (PubMed Search)

Posted: 11/25/2017 by Brian Corwell, MD
Click here to contact Brian Corwell, MD

Tibial shaft stress fractures

An overuse injury where the tibia is subjected to repetitive stress resulting in progressive microfractures

Commonly seen in runners and military recruits

Location of injury is very important for prognosis and treatment

1)      Medial tibia (compression side) – Most common stress fracture site in athletes (runners)

2)      Anterior tibia (tension side) – Seen in repetitive jumping  athletes

History: Change in routine (volume or surface), Insidious onset of pain, worse with activity better with rest

Exam: Focal tenderness to palpation (versus larger diffuse area with shin splints)

Radiology: Plain film often normal in first 2 to 3 weeks

Lateral X-ray may show the “dreaded black line” on the anterior tibia

MRI has replaced bone scan as most sensitive for early diagnosis. Fracture line surrounded by edema.

Treatment:

Medial fractures: relative rest (avoid painful activities), avoid NSAIDs, PT, gradual return to activity as dictated by symptoms

VERSUS

Anterior stress fracturesVery high risk injury pattern (delayed union and non union). Non weight bearing splint/cast. Intramedullary nail often used for failure of conservative treatment or earlier return to sport in competitive athletes.

Dreaded black line picture:

https://www.researchgate.net/profile/Brian_Werner2/publication/265054294/figure/fig2/AS:295959096512514@1447573555901/Figure-2-A-Lateral-plain-radiograph-showing-the-%27%27dreaded-black-line%27%27-highlighted.png


As we are approaching the winter in the northern hemisphere, the number of visits for ear pain or respiratory symptoms are expected to increase.  The occurrence of acute otitis media (AOM) will also increase, but are these two disease processes related?

Drs. Heikkinen and Chonmaitree published a systematic review of previously reported studies regarding the correlation of these two disease processes (1).  As far back as 1990, studies have shown that up to 94% of pediatric patients diagnosed with AOM have concomitant upper respiratory infection (URI) type symptoms at time of diagnosis (2).   The viral infections most commonly associated with AOM are respiratory syncytial virus, influenza virus, and adenovirus (3).

The most commonly taught risk factors for developing AOM include young age, male gender, multiple siblings, day care attendance, and passive smoking.  These factors are also related to the development of upper respiratory symptoms, and the development of AOM should be thought of as a complication of the upper respiratory infection (4). 

Koivunen et al noted the highest incidence of AOM at day 3 after the onset of an URI, and the median time to diagnosis was day 4 (5). If you see a patient in day 2-4 of an URI, who has started to develop an ear effusion, but not clinical AOM, you may want to consider a “Wait-to-see” treatment option if the patient meets treatment criteria (https://em.umaryland.edu/educational_pearls/2049/).

Show References


Category: Neurology

Title: Guillain-Barre's less evil twin - CDIP!

Keywords: GBS, weakness, intubation, CSF, LP (PubMed Search)

Posted: 11/22/2017 by Danya Khoujah, MBBS
Click here to contact Danya Khoujah, MBBS

CDIP, or chronic inflammatory demyelinating polyradiculoneuropathy, is an immune-mediated polyneuropathy which presents similarly to Guillain-Barré Syndrome (GBS). However, it is not as dangerous as GBS. Patients present with symmetric proximal and distal weakness with reduced or absent deep tendon reflexes, just like GBS. The difference is that in typical CDIP, patients have prominent sensory signs, no autonomic dysfunction, no facial weakness, no preceding infectious illness, and most importantly no respiratory failure. It also continues to progress past 4 weeks.

CSF is not diagnostic, and may show albuminocytologic dissociation. The diagnostic test is nerve conduction studies. 

Show References


A recent article from JAMA (link below) showed that Ibuprofen and opioids are similarly effective in the short term relief of acute extremity pain when used in combination with acetaminophen.  The study looked at adults with fractures and sprains and randomized them to one of four groups.

  • 400mg Ibuprofen and 1000mg acetaminophen
  • 5mg Oxycodone and 325mg acetaminophen 
  • 5mg Hydrocodone and 300mg acetaminophen
  • 30mg Codeine and 300mg acetaminophen

Pain relief was similar in all groups.

With the growing increase in opioid abuse/addiction it is good to know that in our patients that are not allergic to acetaminophen and ibuprofen (or all medications except for that one that begins with a “D”) we can provide good pain relief without using opioids.

 

https://jamanetwork.com/journals/jama/article-abstract/2661581

Show References


Category: Pediatrics

Title: Pediatric marijuana ingestion

Keywords: Marijuana, symptoms, overdose (PubMed Search)

Posted: 11/17/2017 by Jenny Guyther, MD (Updated: 6/22/2018)
Click here to contact Jenny Guyther, MD

In the US, there are an estimated 22.2 million users of cannabis based on the 2015 National Survey on Drug Use and Health.  The incidence of unintentional cannabis ingestion has increased in states that have legalized medical and recreational marijuana.  The cited article reviewed of 44 articles involving unintentional cannabis ingestion in children younger than 12 years.

The majority of intoxications were through cannabis resins followed by cookies and joints.

Lethargy was the most common presenting sign followed by ataxia.  Tachycardia, mydriasis and hypotonia were also noted.  Rarer but more serious presentations included respiratory depression and seizures.

Show References


Category: Toxicology

Title: When to hemodialyze in Lithium Toxicity

Keywords: Hemodialysis, lithium (PubMed Search)

Posted: 11/16/2017 by Kathy Prybys, DO (Emailed: 11/17/2017) (Updated: 11/17/2017)
Click here to contact Kathy Prybys, DO

Lithium salts have been used therapeutically for over a 150 years to sucessfully treat manic depressive symptoms, schizoaffective disorder, and cluster headaches. Lithium has a narrow therapeutic range (0.6-1.5 meq/L) and is 100% eliminated by the kidneys. Multisystem toxicity occurs however CNS toxicity is significant and consist of confusion, lethargy, ataxia,  neuromuscular excitability (tremor, fasciculations, myoclonic jerks, hyperreflexia). Since there is a poor relationship between serum concentration and toxicity in the brain, serum blood levels may not reflect extent of toxicity . The goal of enhanced elimination is to prevent irreversible lithium-effectuated neurotoxcity which causes persistant cerebellar dysfunction with prolonged exposure of the CNS to high lithium levels.

Decision for hemodialysis is determined by clinical judgement after considering factors such as lithium  concentration, clinical status of patient, pattern of lithium toxicity (acute vs. chronic), concurrent interacting drugs, comorbid illnesses, and kidney function. Strongly consider hemodialysis for the following: 

  • Manifestations of severe lithium poisoning
  • Impaired kidney function
  • Decreased level of consciousness, seizures, or life threatening dysrhythmias irrespective of lithium concentration
  • Lithium level greater than 5

 

Show References


Mechanical Ventilation in Shock

  • Emergency physicians and intensivists routinely resuscitate patients in shock.
  • For patients who manifest signs of persistent shock (i.e., rising lactate), consider intubation and mechanical ventilation, even in the absence of acute respiratory failure.
  • The respiratory muscles are avid consumers of oxygen.  In fact, up to 50% of available O2 can be used by the respiratory muscles to perform the work of breathing.
  • Initiation of mechanical ventilation can reduce oxygen consumption and allow oxygen to be shunted to other vital organs.

Show References


Category: Orthopedics

Title: Parsonage Turner syndrome

Keywords: Shoulder pain, neuritis (PubMed Search)

Posted: 11/11/2017 by Brian Corwell, MD (Updated: 6/22/2018)
Click here to contact Brian Corwell, MD

Parsonage Turner syndrome aka Neuralgic amyotrophy

 

30 cases per 100,000

Under recognized and often missed

Unknown cause, perhaps post viral. Also reported post stress (surgery, pregnancy)

Can be B/L in 10 to 30%

CC: sudden onset of severe pain in the shoulder.

Can last for hours to weeks.

Radiates to upper arm.

As pain begins to subside, muscle weakness and sensory loss follows.

Can preferentially involve the suprascapular and axillary nerve.

Outpatient workup may include MRI and EMG

Treatment: Supportive. Consider a trial of oral steroids. Provide good pain control.

Majority of patients improve within 3 months. Though up to a third have persistent pain/functional deficit.


Category: Toxicology

Title: Do you have digoxin-like toxins growing in your backyard?

Keywords: cardioactive steroids, cardioactive glycoside (PubMed Search)

Posted: 11/9/2017 by Hong Kim, MD, MPH (Updated: 6/22/2018)
Click here to contact Hong Kim, MD, MPH

Many medications are discovered from plants (quinine – cinchona trees) or organisms (penicillin – mold [penicillicum]).

Digoxin was isolated from foxglove (Digitalis lanata), a colorful floral plant often found in many gardens.  There are other sources of cardioactive steroids (aka cardiac glycosides) that have similar effect as digoxin.

  • Oleander (Nerium oleander)
  • Yellow orleaner (Thevetia peruviana) – frequently used for suicide in Southeast Asia
  • Lily of the valley (Convallari majalis) – use in wedding bouquet
  • Dogbane (Apocynum cannabinum)
  • Red squill (Urginea maritima)
  • Bufo toad (Bufo species)  

 

Non-digoxin cardioactive steroid exposure can result in a positive digoxin level due to cross reactivity. This confirms exposure; however, the “digoxin level” does not represent the true extent of the ingested dose or toxicity. 

Non-digoxin cardioactive steroid toxicity

  • Digibind also binds to non-digoxin cardioactive steroids.
  • However, larger doses are often required (initial dose: 10 to 20 vials) than doses required for digoxin toxicity.