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:
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.
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.
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.
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.
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:
Bottom Line:
**IBW calculated using Devine’s formula for men and women:
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
Different chemical, food or pharmaceutical agent exposure can change the color of the urine.
What could cause this patient's urine to turn green?
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 fractures: Very 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:
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/
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.
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
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.
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:
Mechanical Ventilation in Shock
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.
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.
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
Take Home Point: This small but interesting study looked at the incidence of isolated aphasia presenting for concern of stroke. They found that none of their patients had evidence of an infarct, suggesting that strokes affecting language without motor or sensory deficits are uncommon.
Should that patient be admitted to the floor?
Several studies have evaluated factors associated with upgrade in admitted patients from the floor to an ICU within 24 or 48 hours. Elevated lactate, tachypnea, and "after-hours" admissions have been repeatedly identified as some of the risk factors for decompensation.
Two recent studies tried again to identify predictors of eventual ICU requirement...
Best predictors of subsequent upgrade:
The most common reasons for upgrade:
Effect on mortality?
Despite a more stable initial presentation, mortality of patients who decompensated on the floor (25%) matched that of patients initially admitted to the ICU.
*One of the studies noted that although respiratory rate was demonstrated to be the most important vital sign, it was missing in 42% of the study population, while PCO2 was only obtained in 39% of patients.
Bottom Line:
| Strategies for Hyperkalemia Management | |
| Stabilize cardiac membrane | Calcium gluconate |
| Intracellular movement in skeletal muscles | Albuterol Sodium Bicarbonate Insulin |
| Potassium excretion | Loop Diuretics Kayexalate Patiromer (chronic use only) |
| Potassium removal | Dialysis |
Insulin mechanism of action for hyperkalemia:
· Binds to skeletal muscle receptors
· Increased activity of the sodium-potassium adenosine triphosphatase and glucose transporter GLUT4
· Glycemic response occurs at lower levels of insulin
· Potassium transport activity increases as insulin levels increase
Patients with insulin resistance due to type-2 diabetes do not become resistant to the kalemic effects of insulin.
Hypoglycemia following insulin administration for hyperkalemia:
· Occurs 1-3 hours post dose, even with initial bolus of dextrose
· The amount of glucose is insufficient to replace the glucose utilized in response to the administered dose of insulin
· Insulin’s half-life is increased in ESRD leading to longer duration of action
A systematic review of 11 studies regarding insulin dosing for hyperkalemia:
· 22 patients (18%) experienced hypoglycemia
· Studies that only gave 25 grams (1 amp) of dextrose had the highest incidence of hypoglycemia (30%)
Tips:
· Consider insulin dose reduction in patients with renal failure
· Use an order set to ensure patients receive appropriate POC glucose monitoring to detect delayed onset of hypoglycemia
· Dextrose 50% (25 grams) should be given to all patients with pre-insulin BG <350 mg/dL
Subsequent PRN dextrose 50% (25 grams) should be used to maintain BG >100 mg/dL after insulin administration
Core Temp <32 degrees leads to impaired shivering and confers increased risk for malignant ventricular dysrhythmias. Core Temp <28 degrees substantially increases risk of cardiac arrest.
If in cardiac arrest:
If perfusing rhythm:
Consider addition of more invasive rewarming techniques in those with hemodynamic/cadiac instability or without access to VA ECMO/CPB:
Consider stopping resuscitation efforts if/when:
