UMEM Educational Pearls

Question

US, Canadian and European critical care and toxicology societies recently published a consensus recommendation is the management of CCB poisoning.

Bottom line:

1. First line therapy remains unchanged: IV calcium, atropin, high-dose insulin (HIE) therapy, vasopressor support (norepinephrine and/or epinephrine).

2. Refractory to first line therapy: increase HIE, lipid-emulsion, transvenous pacemaker

3. Refractory shock, periarrest or cardiac arrest: Above (#1 & #2) plus ECMO if available.

Show Answer

Show References



Category: Neurology

Title: Updated Guidelines for Traumatic Brain Injury

Keywords: Brain Trauma Foundation, BTF, guideline, traumatic brain injury, TBI (PubMed Search)

Posted: 10/12/2016 by WanTsu Wendy Chang, MD
Click here to contact WanTsu Wendy Chang, MD

Updated Guidelines for Traumatic Brain Injury

The Brain Trauma Foundation (BTF) Guidelines for the Management of Severe Traumatic Brian Injury (TBI) was recently updated and published in September 2016.

Updated recommendations include:

  • Prophylactic hypothermia is not recommended (Level IIB).
  • Phenytoin is recommended for seizure prophylaxis (Level IIA).
    • There is insufficient evidence to recommend levetiracetam over phenytoin.
  • Maintain SBP 100 mmHg for patients 50-69 years old or 110 mmHg for patients 15-49 or >70 years old (Level III).
  • Treat intracranial pressure (ICP) > 22 mmHg (Level III)
  • Target cerebral perfusion pressure (CPP) between 60-70 mmHg (Level IIB).

For the executive summary and complete guidelines, go to https://braintrauma.org/guidelines/guidelines-for-the-management-of-severe-tbi-4th-ed#/



Category: Critical Care

Title: Oxygen-ICU

Posted: 10/11/2016 by Mike Winters, MBA, MD (Updated: 11/9/2024)
Click here to contact Mike Winters, MBA, MD

Question

Oxygen-ICU Trial

  • Recent observational trials have demonstrated an association between hyperoxia and worse outcomes in select critically ill patient populations.
  • The Oxygen-ICU Trial was just published online in JAMA, and was an RCT to assess whether a conservative protocol for oxygen supplementation could improve outcomes in critically ill ICU patients compared with usual care.
  • A total of 236 patients were randomized to the conservative oxgyen group (PaO2 target 70-100 mm Hg, SpO2 94-98%), whereas 244 were randomized to the usual care group (PaO2 up to 150 mm Hg, SpO2 97-100%).
  • The results demonstrated that ICU mortality was lower in patients treated witih a conservative oxygen strategy, with an absolute risk reduction of 8.6%.
  • Take Home Point: Be careful with the tiration of oxygen therapy and avoid hyperoxia in many of your critically ill patients.

Show Answer

Show References



Question

57 year-old female with history of bilateral lung transplants presents with fever, and 2 days of a painful, red, bumpy rash over the left labia and left buttock, but also notes a small tender area on the plantar surface of the left foot.

Below is a figure depicting the location of the rash, as well as a photo of her foot.

Show Answer

Show References



Recurrence depends on age and activity level

27% if >30yo and 72% if <23yo

Surgical Recommendations:

Large bony Bankart lesion, glenoid or humeral head defect >25%, recurrent instability, event near the end of season

Non surgical return to play:

If event occurs at beginning/early in season

Rehabilitation for 2 to 3 weeks (most return to play in this time frame)

Immobilization for 3 to 7 days in simple sling, gentle range of motion, cryotherapy

Physical therapy to strengthen dynamic stabilizers

Shoulder stabilization brace for non overhead throwing and contact sports

Show References



Category: Toxicology

Title: "Leaves of 3 let them be"

Keywords: Poison Ivy, Toxicodendron, Urushiol (PubMed Search)

Posted: 10/6/2016 by Kathy Prybys, MD (Emailed: 10/7/2016) (Updated: 10/7/2016)
Click here to contact Kathy Prybys, MD

Question

Fall clean up = Poison Ivy, oak, sumac (Toxicodendron species) which is ubiquitous in North America but it can also be found in British Columbia, Mexico and in parts of Asia. These plants are truly the scourge of outdoor enthusiasts and agricultural workers responsible for up to 40 million cases of miserable often temporarily incapacitating rashes annually.

Fast Facts:

  • Grows as plant, vine, or shrub with leaves ranging in color from light or glossy green to red and yellow in fall.
  • Exposure by direct contact with plant, indirectly from oil resin on objects, clothes, pets, or airborne from burning plant.
  • Urushiol toxin induced type IV hypersensitivity allergic contact dermatitis. This oily resin toxin is excreted from all parts of plant (stems, leaves, flowers, roots, vines). and is extremely stable staying active even after plant dies.
  • Intensely itchy blistering rash starts 12-72 hours after contact and lasts up to 21 days. Characterized by red streaks or linear configuration where skin brushed up against plant sap. Inflammation (redness, swelling, hives, blistering) to thick leathery plagues depending on severity and vulnerability of skin location. Intense inflammation can mimic cellulitis.
  • Rash is Not contagious but spread of oil on clothes, pets, tools, objects is!
  • Delayed reaction accounts for seemingly "spread" of rash. Eruption rate depends on thickness of skin and dose of urushiol oil.

Treatment Tips:

  • Prevention. Avoidance and universal precautions when gardening. Clusters of 3 leaves each trio growing on their own stem, hairy vines, no thorns, white berries.
  • Cover skin to prevent exposure and if known contact immediately wash skin, clothes, objects.
  • Hot water relieves itch as does cool compresses.
  • Domeboro or witch hazel are astringents can reduce inflammation.
  • External analgesics (e.g., benzocaine, lidocaine, benzyl alcohol) can help itching.
  • Highly viscous or granular cream surfactant washes bind urushiol and can reduce exposure. Zanfel, Mean green, Gojo orange, various generic poison ivy removal scrubs now available. (Zanfel works wonders used every few hours and may alleviate need for steroids but is $$$ and several tubes are required).
  • In severe cases, Steriod burst followed by 2-3 week taper to prevent relapse flare.

Show Answer

Show References


Attachments

1610060530_20161006_035525.jpg (1,535 Kb)

1610060531_20161005_171524.jpg (941 Kb)



Category: International EM

Title: Focused Assessment with Sonography for HIV/TB (FASH- Part 1)

Keywords: Infectious disease, ultrasound, HIV, TB (PubMed Search)

Posted: 9/29/2016 by Jon Mark Hirshon, PhD, MPH, MD (Emailed: 10/5/2016) (Updated: 10/5/2016)
Click here to contact Jon Mark Hirshon, PhD, MPH, MD

Question

What is the FASH Exam?

  • Focused Assessment with Sonography for HIV/TB
  • A new exam suitable for rapid identification of extrapulmonary TB

 

Submitted by Dr. Laura Diegelmann

 

Show Answer

Show References



The delta gap is a measurement intended to assess for mixed acid-base disorders. A straightforward alternative, the strong ion difference (SID), allows for a quick and simple assessment of any non-gap acidosis or alkalosis that may be present.

The SID is simply the difference between the strong cations (Na+, K+, Mg+, Ca+) and the strong anions (Cl-) present in the serum. The abbreviated SID is the difference between the serum sodium and serum chloride levels (approximately 138-102). Values typically range from 36-40 mg/dl. Values less than 36 denote the presence of some degree of hyperchloremic, non-gap, acidosis. While values greater than 40 demonstrate the presence of hypochloremic, non-gap, alkalosis. And while on rare occasions, variations in albumin or elevated levels of cations other than sodium can lead you astray, the SID is as accurate as a delta gap at identifying mixed acid-based disorders without the added mathematical complexity.

Show References



Question

A 41 year old female presenting with intermittent RUQ abdominal pain for 1 week. An ultrasound of the right upper quadrant was performed. What is the diagnosis ?

Show Answer



What they did:

  • End stage renal disease (ESRD) patients presenting to the ED for emergent hemodialysis (HD) with baseline QTc prolongation (>450 msec in men and >470 msec in women) were given antiemetics or antihistamines for symptomatic relief of nausea and pruritis. A repeat ECG was obtained 2 hours after medications were given.
  • Most patients received oral or intravenous promethazine 25 mg, ondansetron 4-8 mg, or diphenhydramine 25-50 mg.

What they found:

  • 44 patients had a mean initial QTc of 483.7 msec (SD 18.4). Two hours after medication administration, the mean QTc was 483.8 msec (SD 20.0).
  • Among 13 patients with initial QTc intervals >500 msec, 9 had an increased QTc interval after medication administration (average increase 11.8 msec, SD 6.7 msec).
  • 8 patients with baseline QTc <500 msec had QTc >500 msec after medication administration.
  • No patients experienced dysrhythmias, death, or were admitted for dysrhythmia or syncope 1 week after medication administration.

Application to clinical practice:

  • While the mean QTc did not change, the proportion of individuals who experienced an increase in QTc interval is not reported.
  • Although greatly limited by a small sample size, this study suggests that usual doses of promethazine, ondansetron, or diphenhydramine in patients presenting for emergent HD with baseline QTc prolongation may be safe.
  • Additional studies, especially in patients with QTc prolongation >500 msec, are warranted.

Show References



Category: Pediatrics

Title: Periumbilical rash (submitted by Greg Shamitko, MD)

Keywords: nickel dermatitis, contact irritant, allergy (PubMed Search)

Posted: 10/1/2016 by Mimi Lu, MD
Click here to contact Mimi Lu, MD

Question

A 12 year old male who recently started middle school presents to the ED with a rash in the periumbilical region that has been developing over the last few weeks. The rash is scaly, somewhat itchy, but otherwise benign appearing. The patient has no known medical conditions other than eczema, and is otherwise well. What is the diagnosis?

Picture courtesy of Mara Haseltine, MD


Show Answer

Show References



Category: Neurology

Title: PCC before LP in Patients on Anticoagulants?

Keywords: lumbar puncture, meningitis, INR, warfarin, spinal, bleeding (PubMed Search)

Posted: 9/28/2016 by Danya Khoujah, MBBS
Click here to contact Danya Khoujah, MBBS

Question

You have a patient in whom you suspect meningitis, but he is on warfarin for a history of pulmonary embolism. You started empirical antibiotics. His INR is 2.6, and you want to do a lumbar puncture (LP) to confirm your diagnosis. Can you use Prothrombin Complex Concentrate to lower his INR and safely perform the LP?

Take Home Point:

Using PCC to lower INR to enable LP is relatively safe and effective in patients on vitamin K antagonists. The dose used was individually determined by the physician according to initial INR.

Limitation:

This is a retrospective study, with no control group. One patient (2.7%) had a myocardial infarction that was “possibly related” to the PCC administration. 

Show Answer

Show References



Category: Critical Care

Title: High Chloride Load Associated with Increased Mortality

Keywords: Fluids, Fluid resuscitation, Metabolic Acidosis (PubMed Search)

Posted: 9/27/2016 by Daniel Haase, MD
Click here to contact Daniel Haase, MD

Question

TAKE HOME POINTS:

-- High chloride load is associated with adverse outcomes in large-volume resuscitation (>60mL/kg in 24h), including increased risk of death [1]

-- Avoid supraphysiologic chloride solutions (i.e. normal saline) when resuscitation volumes are likely to exceed 60mL/kg (e.g. sepsis, DKA)

Show Answer

Show References



Category: Visual Diagnosis

Title: What's the Diagnosis? Case by Dr. Lindsay Weiner

Posted: 9/14/2016 by Tu Carol Nguyen, DO (Emailed: 9/26/2016) (Updated: 9/26/2016)
Click here to contact Tu Carol Nguyen, DO

Question

22-year-old male with history of autism, mental retardation who is non-verbal presents with abdominal pain and vomiting for one day. Patient was found clutching his abdomen and moaning. What's the diagnosis?

 

 

Show Answer

Show References



Category: Orthopedics

Title: Retroperitoneal hemorrhage presenting as an orthopedic complaint

Keywords: Back pain, groin pain (PubMed Search)

Posted: 9/22/2016 by Brian Corwell, MD (Emailed: 9/24/2016) (Updated: 9/24/2016)
Click here to contact Brian Corwell, MD

Retroperitoneal hemorrhage

The pathophysiology is unknown. Some hypothesize that occult vasculopathy and arteriosclerosis of the small vessels in the retroperitoneum may render them friable and therefore prone to rupture. This can be seen in minor trauma in sports and forceful vomiting or coughing. Spontaneous bleeding starts at the microvascular level, and large vessels become disrupted or stretched as the hematoma enlarges.

Retroperitoneal hemorrhage occurs in a variety of clinical circumstances, including spontaneous hemorrhage into a pre-existing benign adrenal cyst or bleeding from a left inferior phrenic artery, tumors of the adrenal gland and kidney, rupture of any blood vessel (most commonly infrarenal aorta); percutaneous interventions (such as cardiac catheterization), trauma, and polycythemia vera,

It is most commonly seen in association with patients with bleeding abnormalities, in HD patients and with anticoagulation therapy,. Risk is much greater with unfractionated heparin therapy than with warfarin. In most of the heparin patients studied, their coagulation parameters were in the therapeutic range.

Patients may present to the non acute area of the ED with back, lower abdominal or groin discomfort, Over time, this may progress to hemodynamic instability, and a fall in hemoglobin, Early identification is crucial to improving patient morbidity and mortality. Early symptoms depend on the location of the bleeding.

Hematoma near or within the iliopsoas muscle usually presents as femoral neuropathy (groin pain or leg weakness).

Femoral neuropathy caused by retroperitoneal hematoma can present with sudden onset severe pain in the affected groin and hip, with radiation to the anterior thigh and the lumbar region. This can easily be missed as the presentation is similar to a pulled msucle or strained hip/back. Iliopsoas muscle spasm often results in the characteristic flexion and external rotation of the hip, and any attempt to extend the hip will result in severe pain. Over time, pain and parasthesia in the antero-medial thigh and leg is seen.

Show References



Category: International EM

Title: Should that NSTEMI post-arrest go to the Cath Lab?

Keywords: Non-communicable diseases, heart attack, cardiac arrest, NSTEMI (PubMed Search)

Posted: 9/21/2016 by Jon Mark Hirshon, PhD, MPH, MD
Click here to contact Jon Mark Hirshon, PhD, MPH, MD

Non –communicable diseases (NCDs), primarily cardiovascular diseases, cancer, respiratory diseases and diabetes, are significantly increasing globally. According to the WHO, cardiovascular diseases alone account for 17.5 million deaths annually- the most of any NCD.

 

If someone has return of spontaneous circulation after cardiac arrest, but does not have ST-elevations on their post-arrest ECG, should you emergently activate the cath lab?

 

In a just released systematic review and meta-analysis in Resuscitation, Dr. Millin and colleagues found that almost one third of patients successfully resuscitated without ST elevation on their ECG had a culprit lesion that would benefit from emergent intervention.

 

Bottom Line: While this is not definitive proof to emergently activate the cath lab for a NSTEMI, it is another strong indication that post cardiac arrest patients without ST elevation may benefit from emergent percutaneous coronary intervention.

Show References



Category: Critical Care

Title: Passive Leg Raise

Keywords: passive leg raise, arterial pressure, pulse pressure variation, volume responsiveness, fluid resuscitation (PubMed Search)

Posted: 9/20/2016 by Mike Winters, MBA, MD
Click here to contact Mike Winters, MBA, MD

Pitfalls with PLR

  • The passive leg raise (PLR) test has become a popular method to assess volume responsiveness in critically ill patients.
  • PLR mobilizes a volume of approximately 150-300 mL and can be used in spontaneously breathing patients, those receiving positive pressure ventilation, or those with various arrhythmias. 
  • In order to properly perform the PLR, you must have a method to monitor cardiac output. (See previously pearl on 7/26/16).
  • Pitfall: Simply monitoring arterial blood pressure alone is not a sufficient method to assess a positive PLR.
  • Pitfalls:Risks of performing a PLR include increased intracranial pressure, reduced cerebral blood flow, and decreased pulmonary compliance.

Show References



Question

A 67 year old female with history of CVA, presented from a nursing home with RUQ abdominal pain and inablitiy to tolerate PO for 3 days. A CT scan of her abdomen was obtained. What is the diagnosis ?

Show Answer

Show References



Category: Orthopedics

Title: PatelloFemoral Syndrome Treatment

Keywords: Patellofemoral Syndrome (PubMed Search)

Posted: 9/10/2016 by Michael Bond, MD (Emailed: 9/17/2016) (Updated: 9/17/2016)
Click here to contact Michael Bond, MD

Patellofemoral Syndrome Treatment options

Patients do best with a combined intervention (ie, exercise therapy, education, manual therapy and taping)  plan or patellofemoral bracing may improve outcomes for people with patellofemoral syndrome and the subtype of patellofemoral osteoarthritis.

For for the ED, we can start NSAIDs, and then have them follow up with Physical Therapy, A sports trainer if in organized sports, or with a sports medicine physician/PCP.  Physical therapy is targeted at strengthening the quadricep muscle particularly vastus medialis, which improves the patella’s tracking with knee flexion.



114 children with bronchiolitis had end tidal carbon dioxide (ETCO2) measured on presentation to the ED. The ETCO2 levels did not differ significantly between admitted and discharged patients. In the subset of admitted patients, there was no correlation with ETCO2 on admission and days of oxygen requirement or length of stay.

Bottom line: Initial ETCO2 does not predict outcome for patients with bronchiolitis.

Show References