UMEM Educational Pearls

Category: Visual Diagnosis

Title: What is the diagnosis ? (Case by Dr. Harry Achterberg)

Keywords: Herpes Zoster Ophthalmicus; Hutchinson's sign (PubMed Search)

Posted: 2/6/2017 by Hussain Alhashem, MBBS (Updated: 9/26/2017)
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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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Category: Geriatrics

Title: Elder Abuse - How Much Are We Missing?

Keywords: physical abuse, neglect, identification (PubMed Search)

Posted: 2/5/2017 by Danya Khoujah, MBBS
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A recent study published in the Journal of American Geriatrics Society aimed to estimate the proportion of visits to US Emergency Departments (EDs) in which a diagnosis of elder abuse is reached.
Results: Elder abuse was diagnosed in 0.013% of the 6.7 million geriatric ED visits that were examined. This is well below the estimated prevalence in the population (which is anywhere from 5-10%).

What That Really Means: There’s a dire need of better identification of elder abuse in the ED, especially neglect, which is the most common and most difficult to identify.

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Category: Pharmacology & Therapeutics

Title: Pharmacy Pearls from the 2016 Surviving Sepsis Guidelines

Keywords: sepsis, antibiotics, vasopressors, shock (PubMed Search)

Posted: 2/4/2017 by Michelle Hines, PharmD (Updated: 9/26/2017)
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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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Category: Critical Care

Title: Surviving Sepsis Guidlines Updated

Keywords: Sepsis, Septic Shock, Fluid resuscitation (PubMed Search)

Posted: 1/31/2017 by Daniel Haase, MD (Updated: 2/18/2017)
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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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Category: Orthopedics

Title: Hand pain in a cyclist

Keywords: nerve, entrapment (PubMed Search)

Posted: 1/28/2017 by Brian Corwell, MD
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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 4th and 5th 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 4th and 5th 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 1st 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 4th and 5th digits with grossly normal motor and sensory function.


Category: Pediatrics

Title: Pediatric Anaphylaxis "Rule of 2's"

Keywords: epinephrine, auto-injector (PubMed Search)

Posted: 1/27/2017 by Mimi Lu, MD
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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!!)


Takeaways

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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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: 9/26/2017)
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Takeaways

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, DO (Emailed: 1/20/2017) (Updated: 1/20/2017)
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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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Category: International EM

Title: Opioids- A Major Killer

Keywords: Opioids, overdose, injury, death (PubMed Search)

Posted: 1/18/2017 by Jon Mark Hirshon, MD, MPH
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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: 9/26/2017)
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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 Bronchospasm (EIB) in Athletes

Keywords: Airway, wheezing, exercise (PubMed Search)

Posted: 1/14/2017 by Brian Corwell, MD (Updated: 9/26/2017)
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Respiratory symptoms are often the basis for the diagnosis and treatment of EIB.

Self-reported Sx’s (cough, chest tightness, SOB, wheezing) have both poor sensitivity and poor specificity for diagnosis.

          Of these, wheezing is most predictive

Symptoms do not correlate with changes in airway caliber in athletes with EIB.

78% of family physicians and almost 50% of pulmonologists start empiric treatment before exercise based on reported symptoms.

Approximately 50% of athletes with symptoms of EIB in this study did not have EIB when PFTs were performed.

Physicians should not rely solely on symptoms for EIB diagnosis.

Also, improvement in self-reported symptoms after administration of beta2 agonists should not be used to make a formal diagnosis.

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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, MPH (Updated: 9/26/2017)
Click here to contact Hong Kim, MD, MPH

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
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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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Takeaways

--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: 9/26/2017)
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Takeaways

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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