Background:
ED Algorithm For Patients with Possible Ebola
If yes to both identification questions, then:
Bottom line:
Whether the patient has Ebola or not, a well-developed response is necessary for patient management and public health preparedness. The fear of the disease is much more widespread and impactful than the disease itself.
See the full algorithm, with more details at: http://www.cdc.gov/vhf/ebola/pdf/ed-algorithm-management-patients-possible-ebola.pdf
Heart Failure & Pulmonary Hypertension (Part I)
~50% of patients with heart failure & preserved ejection fraction (HFpEF) develop pulmonary hypertension (PH)
HFpEF with PH portends reduced survival and increased hospitalization rates compared to those without PH
HFpEF-PH is often confused with idiopathic pulmonary hypertension (IPAH) given the similar hemodynamics; differentiating them is challenging and requires careful consideration of clinical, radiologic, and hemodynamic data
|
| PAH | HFpEF |
| Clinical parameters: | ||
| Age | Typically 3rd–5th decade | Typically 6th–8th decade |
| Comorbidities (HTN, HLD, DM, CAD) | Rare | Common |
| Atrial arrhythmias | Rare | Common |
| Obstructive sleep apnea | Rare | Common |
| Echocardiographic parameters: | ||
| LA size/volume | Normal | Increased |
| LV diastolic function | Normal to mildly abnormal | Moderate to severely abnormal |
| Hemodynamic parameters: | ||
| Resting PAWP | Always <15 mmHg | May be < or >15 mmHg |
| Response to volume | PAWP <15 mmHg (increase ≤5 mmHg) | PAWP >15 mmHg (increase >5 mmHg) |
| Response to exercise | PAWP <15 mmHg (increase ≤5 mmHg) | PAWP >15 mmHg (increase >5 mmHg) |
(Table reproduced from article)
Iliocostal syndrome aka iliocostal friction syndrome
Consider this entity in an elderly patient with osteoporosis with unexplained abdomen/flank or back pain.
Osteoporosis and/or vertebral compression fractures can result in a narrowing of the distance between .
the lowest anterior rib and the top of the iliac crest producing pain where this rib contacts the pelvis.
This can be perceived as side or back pain. This pain can restrict walking leading to a possible misdiagnosis of spinal stenosis. Treatment is with physical therapy and therapeutic injection.
http://www.caringmedical.com/wp-content/uploads/2013/09/iliocostalis.syndrome.jpg
The 2013 neurosurgery guidelines mention two of the more controversial therapies used in spinal cord injuries:
- “MAP Push” (maintaining the patient’s MAP 85-90mmHg, which theoretically increases the blood flow to the penumbra): evidence for the particular MAP goal is not great, but studies show that ICU level monitoring for the first 7-14 days improves outcome as patients may have delayed cardiovascular or pulmonary instability
- Steroids are not recommended anymore (they were an “option” in the previous guidelines)
Choosing Wisely in the ICU
The Critical Care Societies Collaborative came up with this list for ICU providers
1. Don’t order diagnostic tests at regular intervals (such as every day) but rather in response to specific clinical questions. Do you really need a daily INR check or CBC check in all ICU patients? Really?
2. Don’t transfuse red blood cells in hemodynamically stable, non-bleeding ICU patients with a hemoglobin concentration greater than 7 g/dl. See last week’s Pearl!
3. Don’t use parental nutrition in adequately nourished critically ill patients within the first seven days of an ICU stay. TPN is the Cinnamon Toast Crunch of fungi.
4. Don’t deeply sedate mechanically ventilated patients without a specific indication and without daily attempts to lighten sedation. Use as little as possible when you can.
5. Don’t continue life support for patients at high risk for death or severely impaired functional recovery without offering patients and their families the alternative of care focused entirely on comfort. Engage families early in the hospital stay regarding aggressive life-sustaining treatments. Get palliative care involved in the ED!
13 year-old right-hand dominant following assault with blunt object. What’s the diagnosis?
Cardiovascular Morbidity & Sleep Apnea
Obstructive sleep apnea (OSA) is characterized by sleep-related periodic breathing, upper-airway obstruction, sleep disruption, and hemodynamic perturbations
Epidemiological data shows a strong association between untreated OSA & cardiovascular morbidity/mortality
Two recent studies by Gottlieb et al. (1) & Chirinos et al. (2) elucidated two important explicit and complicit treatment considerations for OSA
(1) In moderate-to-severe obstructive sleep apnea, the use of CPAP alone during sleep may ameliorate systemic hypertension and cardiovascular risk, even in patients who do not have "subjective" sleepiness
(2) Weight loss combined with CPAP use may further decrease cardiovascular morbidity
The Reverse Segond Fracture
Most people have heard of a segond fracture (avulsion fracture of the lateral tibeal platuea) seen on knee xrays which is a marker for Anterior Cruciate Ligament and medial meniscus injuries. See Pearl https://umem.org/educational_pearls/1015/
However, there is also a Reverse Segond Fracture that is another benign appearing avulsion fracture of the medial tibeal plateau that is marker for significant injury to the Posterior Cruciate Ligament (PCL).
If a Segond or Reverse Segond Fracture is seen consider immobilzing the patients knee until they can follow up with Orthopedics and/or get an MRI to determine if additional injuries are present.
The world of pediatrics is still working on catching up to adult literature in terms of lactate utilization and its implications. The study referenced looked at over 1000 children admitted to the pediatric intensive care unit. Lactate levels were collected 2 hours after admission and a mortality risk assessment was calculated within 24 hours of admission (PRISM III). Results showed that the lactate level on admission was significantly associated with mortality after adjustment for age, gender and PRISM III score.
Bottom line: In your critically ill pediatric patient, lactate may be a useful predictor of mortality.
With all the current concern about Ebola, it is important to understand what are quarantine and isolation and who can order these.
Per the Centers for Disease Control:
Federal Law allows for quarantine and isolation:
State laws allows for the enforcement of isolation and quarantine within their borders.
Bottom Line:
Valproic acid (VPA) is often used to treat seizure disorder and mania as a mood stabilizer. The mechanism of action involves enhancing GABA effect by preventing its degradation and slows the recovery from inactivation of neuronal Na+ channels (blockade effect).
VPA normally undergoes beta-oxidation (same as fatty acid metabolism) in the liver mitochondria, where VPA is transported into the mitochondria by carnitine shuttle pathway.
In setting of an overdose, carnitine is depleted and VPA undergoes omega-oxidation in the cytosol, resulting in a toxic metabolite.
Elevation NH3 occurs as the toxic metabolite inhibits the carbomyl phosphate synthase I, preventing the incorporation of NH3 into the urea cycle.
Signs and symptoms of acute toxicity include:
Laboratory abnormalities
Treatment: L-carnitine
Hemoglobin Threshold in Septic Shock
A neck ultrasound is performed during endotracheal intubation. What is labeled "A", what is labeled "B" and what's the diagnosis?
Kounis Syndrome (Part II)
- KS can develop from multiple etiologies: hymenoptera, proteins, vasoactive amines, histamine, acetylcholine, multiple antibiotics, and various medical conditions (angioedema, serum sickness, asthma, stress-induced cardiomyopathy).
- Hypersensitivity myocarditis and KS are two cardiac entities of allergic etiology affecting the myocardium and coronary arteries, respectively. These two entities can mimic each other and can be clinical indistinguishable.
- Presence of eosinophil’s, atypical lymphocytes, and giant cells on myocardial biopsy suggests hypersensitivity myocarditis.
- There is evidence showing use of corticosteroids with vasospastic angina with evidence of allergy or the presence of symptoms refractory to high-dose vasodilators has been reported to resolve symptoms.
There is no effective pharmacologic treatment known to hasten recovery from concussion. In future pearls we will examine possible interventions that may help.
The importance of educating our patients was demonstrated in two studies looking at concussion education. Patients were separated into 2 groups. The intervention group received a booklet of information discussing common symptoms of concussion, suggested coping strategies and the likely time course of recovery. At a 3 month follow-up evaluation, the intervention group reported fewer symptoms. This was repeated in pediatric patients with similar results.
Take Home: Consider taking the time to put such an information sheet together for concussed patients seen in the ED.
In a precursor to a forthcoming international guideline on the management of calcium channel blocker poisoning, a new systematic review has been published assessing the available evidence.
A few findings from the systematic review:
Stay tuned for the international guideline coming out soon. One treatment recommendation from the new guideline, reported at the 8th European Congress on Emergency Medicine last month, is not to use glucagon.
Hydrocephalus is a disorder of cerebrospinal fluid (CSF) accumulation. Acute obstructive hydrocephalus such as in subarachnoid hemorrhage and CSF shunt malfunction can cause a rapid rise in intracranial pressure. Nonobstructive hydrocephalus is associated with subacute symptoms. Clinical features of acute obstructive hydrocephalus include headache, blurred vision, papilledema, ocular palsies, nausea and vomiting, and decreased level of consciousness.
Evaluation of hydrocephalus in the ED should include neuroimaging, typically noncontrast head CT given its wide availability. CT characteristics of hydrocephalus can be seen in Figure 1: ventriculomegaly with dilated 3rd ventricle, dilated 4th ventricle, and presence of temporal horns.
When evaluating patients with pre-existing hydrocephalus for worsening symptoms, such as in the evaluation of CSF shunt malfunctions, it is helpful to compare the head CT or MRI for interval ventricular enlargement. Two simple measurements can be taken on a CT or MRI for objective comparisons (Figure 2).
Evans' ratio = A/B = Maximum width of frontal horns (A) divided by maximum width of inner skull (B) at the same CT/MRI level
C = Width of 3rd ventricle
Use of acetazolamide to decrease CSF production is not effective in long-term treatment of hydrocephalus. About 75% of patients with hydrocephalus require CSF shunt placement.
We are proud to announce the release of our new UMEM Pearls App, now available in the Apple App Store and the Google Play Marketplace! You will now be able to pull down pearl content for offline viewing, in addition to having all of the pearls in searchable format available on your mobile devices.
Click either of the following links on your mobile device to download your Pearls App today!
