UMEM Educational Pearls

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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Category: Pediatrics

Title: Can you glue a pediatric nail bed laceration?

Keywords: Nail bed injuries, wound closure (PubMed Search)

Posted: 1/20/2017 by Jenny Guyther, MD (Updated: 11/9/2024)
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Question

More studies are needed, but the existing data shows that medical adhesives may be quicker without impacting cosmetic and functional outcome.

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Category: Toxicology

Title: Urine drug testing

Keywords: Urine Drug Sreen (PubMed Search)

Posted: 1/19/2017 by Kathy Prybys, MD (Emailed: 1/20/2017) (Updated: 1/20/2017)
Click here to contact Kathy Prybys, MD

Urine drug screens are most commonly performed by immunoassay technology utilizing monoclonal antibodies that recognizes a structural feature of a drug or its metabolites.  They are simple to perform. provide rapid screening, and qualitative results on up to 10 distinct drug classes with good sensitivity but imperfect specificity. This can lead to false positive results and the need for confirmatory testing. UDS  does not detect synthetic opiates or cannabinoids, bath salts (synthetic cathinones), and  gamma-hydroybutyrate. Most common drug classes detected are the following:

  • Opiates
  • Methadone
  • Benzodiazepines (not all)
  • Amphetamines 
  • Cocaine
  • THC metabolites
  • Barbituates
  • LSD
  • PCP
  • MDMA (Ecstasy)

 

 

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·       Opioid deaths, such as from heroin and prescription opioids, are a major problem globally

·       In the U.S., since 1999 overdose deaths from prescription opioids have quadrupled.

o   Almost half of opioid deaths involve a prescription opioid

·       The most common drugs related to prescription opioid deaths are:

o   Methadone

o   Oxycodone

o   Hydrocodone

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Category: Critical Care

Title: Ultrasound Guided Radial Arterial Lines

Keywords: Arterial Line, Ultrasound (PubMed Search)

Posted: 1/17/2017 by Rory Spiegel, MD (Updated: 11/9/2024)
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It is not uncommon for critically ill patients to require invasive monitoring of their blood pressure. In these patients, radial arterial lines are often inserted. Traditionally these lines are placed using palpation of the radial pulse. This technique can lead to unacceptably high failure rate in the hypotensive patient commonly encountered in the Emergency Department.

A recent meta-analysis by Gu et al demonstrated the use of dynamic US to assist in the placement of radial arterial lines decreased the rate of first attempt failure, time to line insertion and the number of adverse events associated with insertion.

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Category: Orthopedics

Title: Exercise-induced laryngeal obstruction (EILO)

Keywords: Airway, wheezing, exercise (PubMed Search)

Posted: 1/14/2017 by Brian Corwell, MD (Updated: 6/26/2021)
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You are covering a sporting event or working an ED shift when a young adolescent athlete without significant PMH presents with SOB and wheezing associated with exercise.

You immediately think exercise-induced asthma, prescribe a short-acting bronchodilator and pat yourself on the back.

While you may be right, there is increasing recognition of an alternative diagnosis

Exercise-induced laryngeal obstruction (EILO)

During high intensity exercise, the larynx can partially close, thereby causing a reduction in normal airflow. This results in the reported symptoms of SOB and wheezing.

This diagnosis has previously been called exercise induced vocal cord dysfunction. As the narrowing most frequently occurs ABOVE the level of the vocal cord, EILO is a more correct term.

While exercise induced bronchoconstriction has a prevalence of 5-20%, EILO is less common with a prevalence of 5-6%.

Patients are typically adolescents, with exercise associated wheezing and SOB, frequently during competitive or very strenuous events. Wheezing is inspiratory and high-pitched. Symptoms are unlikely to be present at time of medical contact unless you are at the event as resolution occurs within 5 minutes though associated cough or throat discomfort can persist after exercise cessation. EIB symptoms typically last up to 30 minutes following exercise.

Inhaler therapy is unlikely to help though some athletes report subjective partial relief. This may be explained as approximately 10% of individuals have both EIB and EILO.

In athletes with respiratory symptoms referred to asthma clinic, EILO was found in 35%.

Consider EILO in athletes with unexplained respiratory symptoms especially in those with ongoing symptoms despite appropriate therapy for EIB.

 

 

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Category: Toxicology

Title: Risk factors of severe outcome in acute salicylate poisoning

Keywords: salicylate poisoning (PubMed Search)

Posted: 1/13/2017 by Hong Kim, MD (Updated: 11/9/2024)
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A small retrospective study of an acute poisoning cohort attempted to identify risk factors for severe outcome in salicylate poisoning.

Severe outcomes were defined as

  1. Acidemia pH < 7.3 or bicarbonate < 16 mEq/L
  2. Hemodialysis
  3. Death

A multivariate analysis of 48 patients showed that older age and increased respiratory rate were independent predictors of severe outcomes when adjusted for salicylate level.

Initial salicylate acid level was not predictive of severe outcome.  

Elevated lactic acid level was also a good predictor of severe outcome in univariate analysis but not in multivariate analysis.

Limitations

  1. Small sample size with single center study
  2. Retrospective study design
  3. Validation study of these predictors is needed.

 

Bottom line

  1. Older age and increases respiratory rate is associated with severe outcome (acidemia, hemodialysis or/and death) in this study.
  2. Data must be interpreted with caution due to small sample and retrospective study design.

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Category: Neurology

Title: Driving after concussion: Is it safe to drive after symptoms resolve?

Keywords: concussion, driving performance, cognitive impairment (PubMed Search)

Posted: 1/11/2017 by WanTsu Wendy Chang, MD
Click here to contact WanTsu Wendy Chang, MD

 
Driving after concussion: Is it safe to drive after symptoms resolve?
  • Limited data is available to guide when individuals should return to driving after a concussion.
  • Cognitive impairments in reaction time, executive function, and attention can persist even after symptoms of a concussion resolve.
  • Schmidt et al. compared driving performance between individuals within 48 hours following symptom resolution after a concussion with matched controls using simulated driving.
  • They found that concussed individuals had poorer driving performance despite being asymptomatic.
  • This study is limited by a small sample size (n=28), however, it raises interesting questions regarding whether driving should be restricted following concussions and how should readiness to return to driving be determined.

 

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Question

--Recent meta-analysis comparing continuous infusion versus intermittent bolus dosing of beta-lactam antibiotics demonstrates mortality benefit (NNT = 15) in patients with severe sepsis or septic shock. (1)

--Consider beta-lactam continuous infusion on your septic patients if your hospital pharmacy allows

[Thanks to Anne Weichold, CRNP for providing the article for this pearl!]

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Question

A 60 year-old man with history of atrial fibrillation, CAD presents with left lower leg/foot pain for a few days. His foot is seen below. What's the diagnosis?

 

 

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Category: Pharmacology & Therapeutics

Title: Ketorolac's analgesic ceiling

Keywords: ketorolac, NSAID, analgesia (PubMed Search)

Posted: 1/7/2017 by Michelle Hines, PharmD (Updated: 11/9/2024)
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Question

In a study comparing ketorolac IV doses of 10 mg, 15 mg, and 30 mg, no difference in pain score reduction or need for rescue analgesia was observed.

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Category: Toxicology

Title: Unexplained Lactic Acidosis, a clue to poisoning

Keywords: Lactic acidosis (PubMed Search)

Posted: 1/5/2017 by Kathy Prybys, MD (Emailed: 1/6/2017) (Updated: 1/6/2017)
Click here to contact Kathy Prybys, MD

Lactic acidosis is the most common cause of anion gap metabolic acidosis in all hospitalized patients. An elevated lactate level is an important marker of inadequate tissue perfusion causing subsequent shift to anaerobic metabolism and occuring in a variety of disease states such as sepsis. In patients with unexplained lactic acidosis without systemic hyoperfusion or seizure suspect  the following toxins:

  • Acetaminophen: Early on in massive ingestion usually associated with coma.
  • Cyanide
  • Metformin
  • HIV Drugs: Nucleotide reverse transcriptase inhibitors = Didanosine, stavudine, zidovudine due to mitochondrial toxicity.
  • Ethylene Glycol: Spuriously elevated lactate may occur with ethylene glycol toxicity due to the structural similarity between glycolic acid and lactate.Check for osmolar gap.
  • Kombucha ``mushroom'' tea 
 

 

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Category: International EM

Title: Vitamin B12 Deficiency: Part 2

Keywords: B12 deficiency, ataxia, dementia, pernicious anemia (PubMed Search)

Posted: 1/4/2017 by Jon Mark Hirshon, PhD, MPH, MD
Click here to contact Jon Mark Hirshon, PhD, MPH, MD

Vitamin B12 deficiency can cause significant disease, including severe neurologic problems. However, patient presentations can vary greatly.

Signs and symptoms can include:

  • Constitutional symptoms: fatigue, lack of energy, lightheadedness, loss of appetite
  • Gastrointestinal problems: diarrhea or constipation
  • Cardiovascular: shortness of breath, dyspnea on exertion, tachycardia, CHF
  • Oral lesions: swollen, red tongue (glossitis) or bleeding gums
  • Problems concentrating

Prolonged B12 deficiency can lead to significant neurologic complications, frequently related to the spinal cord, and can include:

  • Mild impairment to dementia
  • Depression, psychosis
  • Loss of balance, limb weakness, ataxia
  • Peripheral neuropathy (numbness and tingling of hands and feet)


PaCO2 and the Post-Arrest Patient

  • Alterations in PaCO2 are common during the post-arrest period and have been associated with worse patient centered outcomes.
  • Hypercarbia can dilate cerebral vessels, increase cerebral blood flow, and may increase intracranial pressure.
  • Conversely, hypocarbia can constrict cerebral vessels and may reduce cerebral blood flow.
  • Though the current evidence is primarily limited to observational trials, a recent meta-analysis found that "normocarbia" was associated with improved hospital survival and neurologic outcome. 
  • Take Home: Adjust mechanical ventilation to target normocarbia (PaCO2 or ETCO2) in the post-arrest patient.

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Question

A 36-year-old male, who recently immigrated from Africa, presented to the ED with fever, rash, cough and shortness of breath. He was noted to be febrile to 39.0 C. The rash is disseminated but present mainly in his trunk as shown in the picture. 

 

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Question

Take Home Point:

  • According to a recent article in the NEJM there does not seem to be any difference in the rate of symptomatic venous thromboembolism (VTE) in patients given low molecular weight heparin that underwent arthorscopy or had lower leg casting at 3 months.  
  • Overall, the rates of VTE were really low ( casting: 1.4% vs. 1.8%; arthroscopy: 0.7% vs. 0.4%), so there is probably not need for prophalaxis in these patients. 

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In pediatrics, providers typically prescribe 10 mg/kg (max 500 mg) and 5 mg/kg daily x 4 (max 250 mg) for treatment of pneumonia, but this dosing regimen is NOT recommended for all azithromycin usage. There are other dosing regimens that are important to keep in mind during the respiratory season:

1) Pharyngitis/ tonsillitis (ages 2-15 yr): 12 mg/kg daily x 5 days (max 500 mg/ 24 hr)

2) Pertussis

3) Acute sinusitis >/= 6 months: 10 mg/kg daily x 3 days

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Category: Toxicology

Title: Utility of lactic acid level for diagnosis of cyanide poisoning in smoke inhalation victims

Keywords: cyanide toxicity, lactic acid (PubMed Search)

Posted: 12/29/2016 by Hong Kim, MD (Emailed: 12/30/2016) (Updated: 12/30/2016)
Click here to contact Hong Kim, MD

Question

Smoke inhalation victims (house fires) are at risk of carbon monoxide (CO) and cyanide poisoning (CN). CO exposure/poisoning can be readily evaluated by CO - Oximetry but CN level can be obtained in majority of the hospital.

Lactic acid level is often sent to evaluate for CN poisoning.

 

Bottom line:

  1. Lactatic acid levels should be sent in all smoke inhalation victims.
  2. Elevate lactate > 10 mmol/L is highly suggestive of CN poisoning
    .

 

 

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Category: Critical Care

Title: Bolus Dose Nitrates in Acute Pulmonary Edema

Keywords: Acute pulmonary edema, Bolus nitrates (PubMed Search)

Posted: 12/27/2016 by Rory Spiegel, MD (Updated: 11/9/2024)
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It is well known that the early aggressive utilization of IV nitrates and non-invasive positive pressure ventilation (NIV) in patients presenting with acute pulmonary edema will decrease the number of patients requiring endotracheal intubation and mechanical ventilation. 

Often our tepid dosing of nitroglycerine is to blame for treatment failure. Multiple studies have demonstrated the advantages of bolus dose nitroglycerine in the early management of patients with acute pulmonary edema. In these cohorts, patients bolused with impressively high doses of IV nitrates every 5 minutes, are intuabted less frequently than patients who received a standard infusion (1,2). No concerning drops in blood pressure in the patients who received bolus doses of nitrates were observed. Using the standard 200 micrograms/ml nitroglycerine concentration, blood pressure can be rapidly titrated to effect.

 

 

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Question

68 year-old male presents with 3-4 days of hedache, anorexia for 2 weeks and "balance trouble." His blood pressure was 226/140 and he states he has not been on his medications for 6 months.
Physical examination revealed a shuffled gait with his walker and the rest of his physical exam and neurologic exam was unremarkable. 
 
His CT is seen below. What's the diagnosis?
 
 
 
 

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