UMEM Educational Pearls

Category: Pediatrics

Title: Risky Business in Bronchiolitis

Keywords: Pediatrics, Bronchiolitis, Respiratory Decompensation, Risk factors (PubMed Search)

Posted: 10/6/2017 by Megan Cobb, MD
Click here to contact Megan Cobb, MD

Takeaways

Bronchiolitis season will soon be upon us. Here are some risk factors for children under 2 y/o with bronchiolitis, who may be more likely to suffer respiratory decompensation:

1. Age under 9 months

2. Black race

3. Hypoxia documented in the ED

4. Persisent accessory muscle use. 

Bottom Line: Consider providing respiratory support sooner than later in bronchiolitic infants with risk factors for decompensation. For HFNC, start at 1.5 - 2.0 L/kg/min, and titrate to work of breathing and  0saturations. 

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Pathophysiology: Bronchiolitis is a disease process that leads to inflammation of lower airways, causing bronchiolar edema, epithelial hyperplasia, mucus plugging, and air trapping or atelectasis. Common viral causes include RSV, Human Metapneumovirus, Rhinovirus, Influenza, and Parainfluenza. 

Clinical Course: For most strains, the disease course is often 5-7 days with the worst days being 3-5. The disease process can last longer, especially in neonates. The predominant presenting symptoms are often rhinorrhea, low grade fevers, and cough, but apnea can be the primary symptom in younger infants. As a result of increased work of breathing, PO feeding tolerance decreases and leads to dehydration. 

Treatment: Primarily supportive care with suctioning, hydration, supplemental oxygen via standard NC, HFNC, and in severe cases BiPAP, CPAP or intubation. Trial of bronchodilator is often used, but there is no role for repeated bronchodilator use if no benefit is seen in pre and posttreatment respiratory effort. Hypertonic saline is not recommended for routine use in the ED. Corticosteroids have no role for routine use in viral bronchiolitis, either.

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Category: Toxicology

Title: Hunan Hand

Keywords: Capsaicin, hunan hand, chili peppers (PubMed Search)

Posted: 10/6/2017 by Kathy Prybys, DO
Click here to contact Kathy Prybys, DO

Hunan hand syndrome is a painful contact dermatitis that frequently presents in cooks and chili pepper workers after preparing or handling chili peppers. Contact with other body parts gives rise to the terms: "Hunan nose" ''Hunan eye",and "Chili Willie". Capsaicin, found in the fruit of plants from the genus Capsicum such as red chili peppers, jalapeños, and habaneros, is a hydrophobic, colorless, odorless compound that binds with pain receptors causing the sensation of intense heat or burning. The "heat" or pungency of a peppers is measured in Scoville heat units (SHU), the number of times a chili extract must be diluted with water to lose heat. Habanero peppers generate 30,000 SHU. Even at low concentrations capsaicin is a skin irritant. It is the primary ingredient in pepper spray used in law enforcement and in personal defense sprays.   

Treatment consists of decontamination with water irrigation for opthalmic exposure and milk or antacids for dermal or gastrointestinal exposure. Burning can be recurrent and of of long duration depending on tissue penetration. Topical anesthetic especially for the eye and cool compresses for the skin can relieve pain.  Parodoxically capsaicin is used as a topical analgesic medication for local pain relief from muscle pain, itching,  and painful neuropathies (diabetic, postherpetic). Capsaicin initially causes neuronal excitation followed by a long-lasting refractory period due to depletion of substance P, during which neurons are no longer responsive to a large range of stimuli and thus are desensitized.

 

 

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Risk of Pneumocystis pneumonia  (PCP) increases with degree of immunosuppression. If clinical suspicion exists (CD4 <200 with cough, pulmonary infiltrates, hypoxic respiratory failure), it is reasonable to initiate empiric therapy. 

First line treatment is trimethoprim-sulfamethoxazole (TMP-SMX) orally or IV for 21 days.  IV pentamidine has equivalent efficacy to IV TMP-SMX but greater toxicity and is generally reserved for patients with severe PCP who cannot tolerate or are unresponsive to TMP-SMX.

Importantly, adjunctive corticosteroids have been shown to significantly improve outcomes (mortality, need for ICU admission, need for mechanical ventilation) in HIV-infected patients with moderate to severe PCP (defined by pO2 <70 mmHg on Room Air).

·      Ideally steroids should be started BEFORE (or at the same time as) Pneumocystis-specific treatment to prevent/mitigate the sharp deterioration in lung function that occurs in most patients after initiation of PCP treatment. This is thought to be secondary to the intense inflammatory response to lysis of Pneumocystis organisms, which can cause an ARDS-like picture.

·      Recommended dosing schedule: 40mg prednisone twice daily for 5 days,  then 40mg once daily for 5 days, followed by 20mg once daily for the remaining 11 days of treatment.

 

Bottom Line: In patients with moderate to severe PCP (pO2 <70 mmHg on RA), don’t forget to initiate adjunctive corticosteroids early (at the same time you initiate empiric therapy for PCP). 

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The current number of influenza cases in the Southern Hemisphere is substantially higher than normal.  For example, in Australia the number of influenza cases this year are twice the next highest year. 

Have you gotten your flu shot yet?

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Takeaways

Providing consistent, quality emergency care to the elderly is critically important. The Geriatric Emergency Department (GED) guidelines, developed collaboratively, provide a standardized set of guidelines to help improve care of the geriatric population in the emergency department.

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Category: Neurology

Title: tPA Contraindications

Keywords: stroke, tPA, thrombolytics, ICH, hemorrhage, adverse events (PubMed Search)

Posted: 9/28/2017 by Danya Khoujah, MBBS
Click here to contact Danya Khoujah, MBBS

Classically, the list of contraindications for tPA in stroke has been extensive and excludes a significant percentage of patients. This scientific statement from AHA clarifies the evidence behind these contraindications, and in short, expands the population of patients that should be considered for tPA.
The following is NOT considered a contraindication for tPA: 
- Age over 80 
- Severe stroke (NIHSS >25)
- Improving symptoms, if patient remains moderately impaired and potentially disabled
- A small (<10 mm) unruptured and unsecured intracranial aneurysm (NOT other vascular malformations)
- Extra-axial intracranial neoplasms (e.g. meningiomas, pituitary adenomas)
- Blood glucose of >400mg/dL that is subsequently normalized
- Seizure at onset of stroke if residual impairment is secondary to stroke not a postictal phenomenon 

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Category: Orthopedics

Title: Lever Sign for ACL tears

Keywords: ACL tear (PubMed Search)

Posted: 9/23/2017 by Brian Corwell, MD (Updated: 6/22/2018)
Click here to contact Brian Corwell, MD

Lever Sign/Lelli’s test

A new test for diagnosing ACL tears

Higher sensitivity (94 - 100%) than the Lachman test (highest sensitivity test to date)

               With time and more study, this may become our new gold standard physical examination test

Very easy to learn and apply to bedside care

Can help with diagnosing partial tears

Area of manipulation is the femur and not the tibia (as in other tests)

Consider incorporating into your standard knee examination

 

https://www.youtube.com/watch?v=T9ujIYIctdw

Original study

https://www.ncbi.nlm.nih.gov/m/pubmed/25536951/

Validation

https://www.ncbi.nlm.nih.gov/pubmed/26753117

Thank you to Ari Kestler for sending

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Category: Pediatrics

Title: Pediatric Acute Respiratory Distress Syndrome (ARDS)

Keywords: ARDS, oxygenation index, OI, PALICC, acute lung injury (PubMed Search)

Posted: 9/22/2017 by Mimi Lu, MD (Updated: 10/27/2017)
Click here to contact Mimi Lu, MD

Since the first description of acute respiratory distress syndrome (ARDS), various consensus conferences (including American-European Consensus Conference (AECC) and the Berlin Conference) have produced definitions focused on adult lung injury but have limitations when applied to children. 

This prompted the organization of the Pediatric Acute Lung Injury Consensus Conference (PALICC), comprised of  27 experts, representing 21 academic institutions and eight countries.  The goals of the conference were 1) to define pediatric ARDS (PARDS); 2) to offer recommendations regarding therapeutic support; and 3) to identify priorities for future research in PARDS.

Although there were several recommendations from the group, some notable ones, in contrast to the Berlin definition focused on adults, include: 1) use the Oxygenation Index (or, if an arterial blood gas is not available, the Oxygenation Severity Index) rather than the P/F ratio; 2) elimination of the requirement for “bilateral” pulmonary infiltrates (may be unilateral or bilateral) 3) elimination of  specific age criteria for PARDS.

Tune in next month for pearls on management for children with PARDS...

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Category: Toxicology

Title: Drug Induced Hyperkalemia

Keywords: Hyperkalemia (PubMed Search)

Posted: 9/22/2017 by Kathy Prybys, DO (Updated: 10/5/2017)
Click here to contact Kathy Prybys, DO

Hyperkalemia is a potentially life threatening problem which can lead to cardiac dysrhythmias and death.  Drug interactions inducing hyperkalemia are extremely common such as the combination of ACE inhibitors and spironolactone or ACE inhibitors and trimehoprim sulfamethoxazole. Hyperkalemia can also occur with a  single agent and is a relatively common complication of therapy with trimethoprim sulfamethoxazole. The following drugs can cause hyperkalemia:

  • Ace inhibitors
  • Beta blockers
  • Cyclosporine
  • Digitalis
  • Non-steroidal Anti-inflammatory Drugs
  • Pentamidine
  • Potassium supplement
  • Succinylcholine
  • Tacrolimus
  • Trimethoprim sulfamethoxazole 

 

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The blue-ringed octopus (genus Hapalochlaena) is normally found in the Great Barrier Reef and other coastal waters and tide pools around Australia and other Western Pacific islands. Though not an aggressive animal, when it does bite, such as stepped upon, it can inject tetrodotoxin along with a number of other toxic compounds.

 

Tetrodotoxin can cause paralysis, leading to respiratory failure and death, though the blockage of voltage-gated fast sodium channel conduction, blocking peripheral nerve conduction. Treatment is supportive, as the venom usually wears off within 4 to 10 hours.

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Post-Arrest Tidal Volume Setting

  • Most patients with ROSC from out-of-hospital cardiac arrest undergo endotracheal intubation and mechanical ventilation.
  • Optimal management of mechanical ventilation for the post-arrest patient is currently not well defined.
  • A recent retrospective cohort study sought to determine if a lower tidal volume (Vt) was associated with improved neurocognitive outcome at hospital discharge.
  • Of 256 patients included in the study, investigators found:
    • 38% were ventilated with Vt > 8 ml/kg predicted body weight
    • Lower Vt was significantly associated with favorable neurocognitive outcome, decreased duration of mechanical ventilation, and decreased ICU length of stay
  • Take Home Pearl: Pay attention to Vt in the post-arrest patient.

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Takeaways

Elective surgeries with general anesthesia are often cancelled when the child has an upper respiratory tract infection.  What are the adverse events when procedural sedation is used when the child has an upper respiratory tract infection?

Recent and current URIs were associated with an increased frequency of airway adverse events (AAE).  The frequency of AAEs increased from recent URIs, to current URIs with thin secretions to current URIs with thick secretions.   Adverse events not related to the airway were less likely to have a statistically significant difference between the URI and non-URI groups

AAEs for children with no URI was 6.3%.  Children with URI with thick/green secretions had AAEs in 22.2% of cases.  Children with URIs did NOT have a significant increase in the risk of apnea or need for emergent airway intervention.  The rates of AAEs, however, still remains low regardless of URI status.

 

 

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During the past several years, several new classes of diabetic medications were introduced for clinical use, including SGLT2 inhibitors (canagliflozin, dapagliflozin and empagliflozin).

SGLT2 inhibitors prevent reabsorption of glucose in the proximal convoluted tubules in the kidney and does not alter insulin release.

A recent retrospective study (n=88) of 13 poison center data from January 2013 to December 2016 showed

  1. 91% of the patients were asymptomatic.  
  2. 7% developed minor symptoms (tachycardia, nausea/vomiting, abdominal pain, & confusion)
  3. 2% developed moderate symptoms (metabolic acidosis, hypertension [166/101], & hypokalemia)
  4. Hypoglycemia was not reported.

49 patients were evaluated in a health care facility (HCF) with 18 admissions. Referral to HCF was more common in pediatric patients. This was likely due to unfamiliarity with a new mediation and lack of toxicity data.

Other case reports have shown higher incidence of DKA with the therapeutic use of SGLT2 vs. other classes of DM medications.

 

Bottom line:

Limit data is available regarding the toxicologic profile of SGLT2 inhibitors.

Based upon this small retrospective study, hypoglycemia may not occur and majority of the patient experience minimal symptoms.

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Category: Neurology

Title: IV vs. Non-IV Benzodiazepines for Cessation of Seizures

Keywords: seizure, status epilepticus, benzodiazepine, RAMPART, pediatric (PubMed Search)

Posted: 9/13/2017 by WanTsu Wendy Chang, MD (Updated: 9/14/2017)
Click here to contact WanTsu Wendy Chang, MD

Takeaways

IV vs. Non-IV Benzodiazepines for Cessation of Seizures

  • A meta-analysis by Alshehri et al. included 11 studies with a total of 1633 patients, comparing IV vs. non-IV benzodiazepines from any route (buccal, intranasal, intramuscular) for seizure cessation in status epilepticus.
  • They found that non-IV benzodiazepine is more effective than IV benzodiazepine in patients presenting without IV access.
  • The largest and highest quality study included in the meta-analysis was the RAMPART study, which was also the only study to include adults.
  • When considering pediatric studies only, there is no difference between IV vs. non-IV benzodiazepine in seizure cessation for status epilepticus.

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Category: Critical Care

Title: Negative-Pressure Pulmonary Edema

Keywords: respiratory failure, pulmonary edema, airway obstruction (PubMed Search)

Posted: 9/12/2017 by Kami Hu, MD
Click here to contact Kami Hu, MD

Takeaways

Negative-pressure pulmonary edema (NPPE) is a well-documented entity that occurs after a patient makes strong inspiratory effort against a blocked airway. The negative pressure causes hydrostatic edema that can be life-threatening if not recognized, but if treated quickly and appropriately, usually resolves after 24-48 hours. These patients may have any type of airway obstruction, whether due to edema secondary to infection or allergy, laryngospasm, or traumatic disruption of the airway, such as in attempted hangings.

Management: 

1.     Alleviate or bypass the airway obstruction.

·      Usually via intubation; may require a surgical airway

·      If obstruction in an intubated patient is due to biting on tube or dyssynchrony, add bite-block (if not already in place), sedation, and even paralysis if needed.

2.     Provide positive pressure ventilation and oxygen supplementation.

3.     Use low tidal volume ventilation.

4.     In severe hypoxemia without shock, add a diuretic agent and consider additional measures such as proning and even ECMO if the hypoxemia is refractory to standard therapy.  

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Category: Orthopedics

Title: Viscosupplementation

Keywords: Knee OA, injection (PubMed Search)

Posted: 9/9/2017 by Brian Corwell, MD (Updated: 6/22/2018)
Click here to contact Brian Corwell, MD

 

Viscosupplementation

Hyaluronic acid (HA) is a high-molecular weight polysaccharide

A major component of synovial fluid and of cartilage

Major role of HA is as a lubricant, shock absorption, antinociceptive effect

               Used in veterinary medicine for decades

Multiple brands exist with differences based on the molecular weight and how they are produced

Use supported by the Cochrane database (2007, 2014) for knee OA

Post injection strength gains are due to pain relief

May have a role for those who cannot receive steroid injections

Inject in similar manner to intra articular steroids

Caution in those with known allergy to poultry /eggs

Risks: Local reaction (likely from preservative), injection site pain, infection, bleeding.


Category: Toxicology

Title: X-rays in poisoning diagnosis?

Keywords: Radiographs, poisoning (PubMed Search)

Posted: 9/7/2017 by Kathy Prybys, DO (Emailed: 9/8/2017) (Updated: 9/8/2017)
Click here to contact Kathy Prybys, DO

Takeaways

Radiographs studies can be valuable in poisoning diagnosis, management, and prognosis.  Radiographic imaging should be utilized for the following toxins:

Heavy metals 
  • Iron (gastrointestinal)
  • Mercury (gastrointestinal, intravenous or subcutaneous)
  • Lead (bullets intraarticular, gastrointestinal foreign bodies, lead lines)
  • Zinc phosphide (gastrointestinal)

Container toxins - Body packers

  • Drug packets and vials

Sustained Released preparations

  • Potassium Chloride
Button Batteries and Coins

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There have been reports of “intoxication” or adverse effects among first responders and law enforcement due to exposure to a “powder” suspected to be fentanyl or its analog.

 

This has led to a significant concern among first responders and law enforcement when investigating or handling “powder” at the scene of overdose or drug enforcement related raids. (http://www.foxnews.com/health/2017/08/15/police-department-gets-hazmat-like-protective-gear-for-overdose-calls.html)

 

American College of Medical Toxicology and American Association of Clinical Toxicology recently published a position statement to help clarify the potential health risk associated with exposure to fentanyl and its analogs.

 

  1. Opioid toxicity is unlikely from incidental dermal exposure.
  2. Nitrile gloves provide sufficient protection against dermal exposure.
  3. N95 respirator provide sufficient protection against aerosolize fentanyl/opioids.
  4. Naloxone should be administered for patients with objective signs of opioid toxicity - hypoventilation and CNS depression – not for vague or subjective symptoms.

Category: International EM

Title: Top Natural Disasters By Death Toll

Keywords: Floods, earthquakes, hurricanes, natural disasters (PubMed Search)

Posted: 9/6/2017 by Jon Mark Hirshon, MD, MPH (Updated: 6/22/2018)
Click here to contact Jon Mark Hirshon, MD, MPH

With the recent destruction by Hurricane Harvey and the impending impact of Hurricane Irma, it is important to recognize the historical death toll from natural disasters. While the list can vary, here is a top ten list from the library of the National Oceanic and Atmospheric Administration:

Rank

Event

Location

Date

Death Toll (Estimate)

1

1931 Yellow River flood

Yellow River, China

Summer 1931

850,000-4,000,000

2

1887 Yellow River flood

Yellow River, China

September-October 1887

900,000-2,000,000

3

1970 Bhola cyclone

Ganges Delta, East Pakistan

November 13, 1970

500,000- 1,000,000

4

1201 Earthquake

Eastern Mediterranean

1201

1,000,000

5

1938 Yellow River flood

Yellow River, China

June 9th, 1938

500,000 - 900,000

6

Shaanxi Earthquake

Shaanxi Province, China

January 23, 1556

830,000

7

2004 Indian Ocean earthquake/tsunami

Indian Ocean

December 26, 2004

225,000-275,000

8

1881 Haiphong Cyclone

Haiphong, Vietnam

1881

300,000

9

1642 Kaifeng Flood

Kaifeng, Henan Province, China

1642

300,000

10

Tangshan Earthquake

Tangshan, China

July 28, 1976

242,000*

* Official Government figure. Estimated death toll as high as 655,000.

 

 

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Category: Geriatrics

Title: Falls in the Elderly (Submitted by Amal Mattu, MD)

Keywords: arrhythmia, syncope, fall (PubMed Search)

Posted: 9/4/2017 by Danya Khoujah, MBBS (Updated: 6/22/2018)
Click here to contact Danya Khoujah, MBBS

20% of unexplained falls in the elderly can be attributed to an arrhythmia.

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