UMEM Educational Pearls

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Treatment of  Low Back Pain

A recent recommendation from the American College of Physicians (Internal Medicine) now recommends nonpharmacologic therapies as the first line treatment of acute or subacute lower back pain lasting 12 weeks or less.  This might bring more people to our Emergency Departments so it is important that we know their current recommendations.

Some nonpharmacologic therapies recommended are:

• Moderate Evidence: Superficial heat
• Low quality evidence: Massage, Spinal manipulation, or accupuncture

For acute back pain they recommend:

• NSAIDs or muscle relaxants
• Acetominophen is NOT recommended. No evidence it is beneficial

For chronic back pain:

• Start with NSAIDs—>tramadol—>duloxetine.
• Opioids are only recommended for treatment failures.

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Question

A 12 year old with arm pain after doing push ups during gym class.  What is the diagnosis?

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Question

The current opioid epidemic is considered the worst drug crisis in American history responsible for 50,000 deaths per year in the US from overdose of heroin and opioid prescription drugs. A 200% increase in the rate of overdose deaths involving opioids occurred between 2000 and 2014. The continued rise in opioid related deaths calls for an urgent need for treatment. Three types of medication-assisted therapies (MATs) are available for treating patients with opioid addiction:methadone, buprenorphine, and naltrexone. Suboxone a combination of buprenorphine and naloxone, is emerging as one of the best choices for the following reasons:

• Buprenorphine is a partial agonist that suppresses opioid withdrawal and cravings.
• Binds opioid receptors with high affinity but low intrinsic activity.
• Lasts 24 hours. Binds opioid receptors to prevent full opioid agonists such as heroin or prescription opioids from binding.
• Less risk for dependency as increasing doses does not result in full opioid effect.
• Less respiratory depression in overdose due to partial effect.
• Naloxone, an opioid antagonist is poorly absorbed by oral route and is added to discourage injecting or snorting of suboxone as it can precipitate severe withdrawal.
• Precipitated withdrawal can occur if other opioids are present with administration of Suboxone. This is particularly important with long acting opioids such as methadone.
• Can be prescribed in the primary care setting and does not require a specialized clinic.
• Comes in 2 or 8 mg tablet or sublingual film.

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Congenital infection with the Zika virus is associated with 5 types of birth defects

·      These are rarely or never seen with other infections during pregnancy

·      These defects are:

1.     Severe microcephaly (small head size) resulting in a partially collapsed skull

2.     Decreased brain tissue with brain damage

3.     Damage to the back of the eye with a specific pattern of scarring and increased pigment

4.     Limited range of joint motion, such as clubfoot

5.     Too much muscle tone restricting body movement soon after birth 

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Sepsis Mimics

• Emergency physicians are well versed in the resuscitation of patients with sepsis and septic shock.
• With the recent publication of the 2016 SSC Guidelines and the emphasis in meeting various quality measures, sepsis is routinely included in the differential diagnosis of critically ill patients.
• Notwithstanding, it is important to consider other disease states that can present similarly to sepsis or septic shock.  Some of these include:
  • Anaphylaxis
  • Adrenal insufficiency
  • DKA
  • Thyroid storm
  • Toxic ingestion or withdrawal

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Question

56 year-old male with history of hypertension presents with complaints of right scrotal swelling and pain. Denies any urinary symptoms, abdominal pain, nausea/vomiting or change in bowel habits or prior episodes. Temp was 99.0.

A scrotal ultrasound was done and an image of the right testis was seen (below). What's the diagnosis?

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Is that a fracture or a growth plate?

Pediatric elbow x-rays are complicated to interpret due to the large number of ossification centers.

Elbow trauma is common in pediatrics.

Ossification centers of the elbow appear in a reliable chronologic pattern which aids in distinguising fractures from growth plates.

Note the age ranges are an estimate with great variability. For example, girls can develop these up to 2 years earlier than boys.

The numbers 1/3/5/7/9/11 correspond to the average age of development of each ossification center

Years of fusion shown below in ()

Capitellum (12-14yo)

Radial head (14-16yo)

Medial epicondyle (16-18yo)

Trochlea (12-14yo)

Olecranon (15-17yo)

Lateral epicondyle (12-14yo)

Pneumonic: "Can't Resist My Team Of Lawyers"

Consider ordering films of both elbows to compare if in doubt.

How is this useful? If the trochlear center is present, but there is no medial epicondyle then you are most likely looking at a fx where the ossification center has been avulsed and displaced. 

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Identifying patients at risk of hypotension during intubation is not always straight forward. The prevalence of peri-intubation hypotension in the Emergency Department has been demonstrated to be approximately 20%.¹ And while certain variables increase the likelihood of peri-intubation hypotension (ex. Shock index> 0.80), no single factor predicts it accurately enough to be used at the bedside.² In the majority of patients undergoing intubation, clinicians should be prepared for peri-intubation hypotension with either vasopressor infusions or push dose pressors.

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Question

24-year-old male with a history of Wagner's Granulomatosis, currently on Cellcept (Mycophenolate Mofetil) and high dose prednisolone, presented with two days of sore throat, malaise and the lesions shown in the picture. What is the diagnosis?

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Below is a list of pharmacy-related pearls from the 2016 Surviving Sepsis Guidelines:

• Fluid resuscitation: 30 mg/kg IV crystalloids within 3 hours (strong recommendation, low quality evidence)
• Vasopressors:
  • MAP target 65 mm Hg (strong recommendation, low quality evidence)
  • Norepinephrine 1st line (strong recommendation, moderate quality evidence). Epinephrine (weak recommendation, low quality evidence) or up to 0.03 Units/min vasopressin (weak recommendation, moderate quality evidence) may be added to NE.
• Antibiotics:
  • Obtain blood cultures prior to administration, but do not delay antibiotics (best practice)
  • Initiate empiric broad-spectrum antibiotics within 1 hour (strong recommendation, moderate quality evidence)
  • Consider double gram-negative coverage in patients with septic shock at high risk of multidrug-resistant pathogen
  • Risk factors for invasive Candida infection: immunocompromised state, TPN, necrotizing pancreatitis, recent major abdominal surgery, recent fungal infection
  • Optimize pharmacokinetic/pharmacodynamic properties- e.g., IV loading dose of vancomycin of 25-30 mg/kg is favored (best practice)
• Corticosteroids: IV hydrocortisone 200 mg per day if hemodynamic stability is not achieved through crystalloids and vasopressors (weak recommendation, low quality evidence)

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At the Society of Critical Care Meeting (SCCM) this month, updates to the Surviving Sepsis Guidelines were released. Recommendations include:

--Initial 30mL/kg crystalloid resuscitation with frequent reassessment of fluid responsiveness using dynamic (not static) measures [goodbye CVP/ScvO2!]

--Initiation of broad-spectrum antibiotics within ONE hour of sepsis recognition [two agents from different classes]

--Further hemodynamic assessement (e.g. echo for cardiac function) if clinical assessment does not reveal the type of shock [get out the ultrasound!]

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Question

25 year-old female with hx of cerebral palsy with significant developmental delay, s/p G-tube who presented with acute hypoxic respiratory failure, hypotension and a distended, tense abdomen. A CT was done with the scout film below. What's the diagnosis?

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During a busy ED shift, your 40yo charge nurse asked you to look at his hand. He is known avid mountain biker. He has pain in his right 4^th and 5^th digits. . He feels a lack of coordination and a feeling of “clumsiness” of the hand. Where is his possible nerve compression and what do you expect to find on exam?

Ulnar nerve entrapment is sometimes called “handlebar palsy.” 

Compression location is Guyon’s canal.

The ulnar nerve supplies the intrinsic muscles of the hand AND the extrinsic muscles for flexion of the 4^th and 5^th digits. This is what aids in a “power grip” and why he may have diminished grip strength on exam.

               Also innervates the ADDuctor pollicis and 1^st dorsal interosseous muscles (pinch)

Note the ulnar nerve also passes through the radial tunnel at the elbow. Entrapment here is called Radial tunnel syndrome or Cubital tunnel syndrome and causes forearm pain and paresthesias in the 4^th and 5^th digits with grossly normal motor and sensory function.

As a follow up to Dr. Winter’s Pearl on Anaphylaxis on 1/24/2017, here’s a handy pearl for pediatric anaphylaxis (part 1).

Anaphylaxis: rapid and potentially life-threatening involvement of at least 2 systems following exposure to an antigen.

Medications (max: adult doses)

• Epinephrine auto-injector (2 doses): 0.15 mg and 0.3 mg
• Methylprednisolone (IV) or prednisone (PO): 2 mg/kg
• Diphenhydramine: 1-2 mg/kg
• Ranitidine: 2 mg/kg

Get it?!?!  Easy right?  Instead of fumbling through an app or reference card during your next case of pediatric anaphylaxis, be a rock star "EM DR" by remembering the “Rule of 2’s”. 

(Can't help it...ya'll know I love my mnemonics!!)

Question

Methadone overdose produces classic signs and symptoms of opioid intoxication - CNS and respiratory depression with pinpoint pupils. However, methadone overdose has also been associated with hypoglycemia – a relatively uncommon adverse effect.

Bottom line:

• Methadone-induced hypoglycemia can occur, although rare, in an acute overdose.

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Patients may present to the ED with new onset weakness due to myasthenia gravis (MG). A group that is frequently missed is late-onset MG, which occurs after the age of 50. It is frequently misdiagnosed as a stroke or transient ischemic attach (TIA).

Two cardinal features:

• fatiguability: must be distinguished from fatigue. 
• fluctuation

Bonus pearl: Ocular symptoms are present in up to 85% of patients with MG, with unilateral ptosis or asymmetric bilateral ptosis being the most common presentations.

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Epinephrine in Anaphylaxis

• Delayed administration of epinephrine for patients witih anaphylaxis is associated with increased morbidity and mortality.
• Providers are often hesitant to administered epinephrine to older patients with anaphylaxis for fear of precipitating an adverse cardiovascular event.
• A recent retrospective study of almost 500 patients demonstrated that older patients were significantly less likely to receive epinephrine, despite meeting the definition for anaphylaxis.
• Furthermore, cardiovascular complications occurred in just 9 patients, 6 of which received an excessive dose via the IV route.
• Take Home Point: There are no absolute contraindications (including age) for epinephrine in patients with anaphylaxis.  Give the initial dose IM into the anterolateral thigh.

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