We've all heard Dr. Bryan Hayes warn us that, "Vanc & Zosyn is NOT the Answer for Everything" but things just got a little more serious, on a whole 'nother level...
Within the past few months, 2 cases of NDM-producing carbapenem-resistant pseudomonas have been reported in the area - one in Delaware and one in Pennsylvania. Previously, the only reported cases were found in Europe.
Few treatment options are currently available for carbapenem resistant organisms.
Appear to have retained some in vitro activity against these organisms, but are generally used as, "drugs of last resort".
Know it exists, take a good history, & know your local antibiogram. Prior to selecting a broad spectrum antimicrobial regimen, try to obtain previous antimicrobial culture data for patients with resistant organism infectious risk factors.
A patient presents with the rash shown below and is treated with penicillin. Fever, headache, and myalgia develop four hours later. What’s the diagnosis?
Lisfranc Fracture:
Typically consists of a fracture of the base of the second metatarsal and dislocation, though it can also be associated with fractures of a cuboid. Common current mechanism of injury is when a person steps into a hole and twists the foot. The original mechanism of injury that was described was when a horseman would fall of their horse with their foot still trapped in a stirrup.
Diagnosis should be considered if patient has difficultly weight bearing with pain on palpation over the 2nd and 3rd metacarpal head with an appropriate mechanism.
Pearls:
Mental health-related visits account for 1.6–6% of ED encounters. Patients with acute psychosis are often brought to the ED for clearance prior to psychiatric evaluation. Is this necessary?
Background: Several adult studies have shown that only 0–4% of patients with isolated psychiatric complaints have organic diagnoses requiring urgent treatment. Routine ED laboratory testing in adults is low yield still, with one study identifying abnormalities in only 2 of 352 patients—both mild hypokalemia. A pediatric study found that 207 of 209 patients were medically cleared.
This study was a retrospective review of pediatric psychiatric patients presenting to a an urban California hospital. They examined 798 patients who had an involuntary psychiatric hold placed by a psychiatric mobile response team.
The authors concluded that few pediatric patients brought to the ED on an involuntary hold required a medical screen and perhaps use of basic criteria in the prehospital setting to determine who required a medical screen (altered mental status, ingestion, hanging, traumatic injury, unrelated medical complaint, sexual assault) could have led to significant savings.
Currently, no effective reversal agent for new oral anticoagulants (e.g. direct thrombin inhibitor, dabigatran, and factor Xa inhibitors: rivaroxaban and apixaban) exists for emergent management of hemorrhagic complications.
Boehringer Ingelheim, the manufacturer of dabigatran, is developing an antibody fragment (Fab) against dabigatran as a reversal agent.1
A small ex-vivo porcine study demonstrated partial reversal of anticoagulation effects, measured by PT, aPTT, clotting time, clot formation time and maximum clot firmness, of dabigatran by PCC and activated PCC, while dabigatran-Fab achieved complete reversal. Recombinant fVIIa did not reverse the anticoagulation effect of dabigatran.2
Caution should be exercised when interpreting these finding as reversal of laboratory values does not necessarily correlate with clinical effect/outcome. However, dabigatran-Fab holds promise as an effective reversal agent of dabigatran.
Dabigatran-Fab is still under development and is not available/approved for clinical use.
Clinical Presentation
Rabies is, initially, a clinical diagnosis. To see what a patient with rabies looks like, check out this 3 minute YouTube video: (There is a bit of commentary by the person who posted it at the beginning that you might want to skip through.)
https://www.youtube.com/watch?v=EZbrNN9KeUI
Bottom Line
Rabies, while a rare disease in the US, can occur through either contact with infected animals (especially while traveling) or via organ transplantation. Recognizing the clinical syndrome is key to diagnosis.
University of Maryland Section for Global Emergency Health
Author: Andi Tenner, MD, MPH, FACEP
Prior literature has demonstrated the safety and feasibility of placing subclavian lines with ultrasound guidance; here's a link to a short educational video describing the technique.
The literature has been varied, however, as to which approach is best for venous cannulation with ultrasound; the supraclavicular (SC) or infraclavicular (IC) approach (see references below)
A recent study evaluated both approaches in healthy volunteers in order to determine which approach is superior for cannulation using ultrasound.
98 patients were prospective evaluated by Emergency Medicine physicians with training in ultrasound. In each patient, both SC and IC views were evaluated on both the left and right sides; each view was given a grade for ease of favorability (no patients were actually cannulated)
Overall, it was found that the SC view was significantly more favorable compared to the IC view; the right SC was non-significantly preferred compared to the left SC.
Risk Modifiers for Concussion and Prolonged Recovery
A history of prior concussion is a risk factor for future concussion (>2x risk).
For individual sports, boxing has the highest risk.
For team sports, football, ice hockey and rugby have the highest risk.
Women’s soccer confers the highest risk for female athletes.
Younger age confers increased risk.
Female sex confers higher risk when comparing similar sports with similar rules.
Those with migraine headaches may be at increased risk.
Risk of prolonged concussion
Most athletes have symptom resolution within one week
Post traumatic amnesia (both retrograde and anterograde) predict increased number and longer duration of symptoms.
Younger age also predicts pronged recovery.
Other studies have found associations with headache lasting greater than 60 hours, fatigue, “fogginess,” or greater than 3 symptoms at initial presentation. Cognitive studies have identified deficits in visual memory and process speed as predictors of prolonged recovery.
A placebo-controlled treatment trial in 26 cocaine-addicted subjects aimed to determine whether dexmedetomidine reverses MAP and HR increases after intranasal cocaine (3 mg/kg).
In a low nonsedating dose, dexmedetomidine may be a potential (adjunct) treatment for cocaine-induced acute hypertension. However, higher sedating doses can increase blood pressure unpredictably during acute cocaine challenge and should be avoided.
Generous benzodiazepine should remain first-line therapy.
General Information:
Relevance to the EM Physician:
Bottom Line:
University of Maryland Section of Global Emergency Health
Author: Jenny Reifel Saltzberg, MD
High Flow Nasal Cannula
What is it?
Benefits
Who to use it on
How to set it
-15-30 L per minute
-100% oxygen (wean as tolerated)
-temp 35-40 C
-when weaning decrease oxygen prior to flow
Bottom line: No evidence that it reduces intubation rates in patients with hypoxemic respiratory failure but may improve oxygenation issues while deciding on treatment options
The clip below demonstrates normal right femoral anatomy. The structure with the asterisk is the right common femoral vein and the arrow is pointing to a branch of the right femoral vein. What is the name of the branch and what is its importance during lower extremity ultrasound?
Four small case series (one prospective, 3 retrospective) have concluded that dexmedetomidine (Precedex) may be a useful adjunct therapy to benzodiazepines for ethanol withdrawal in the ED or ICU. They are summarized on the Academic Life in EM blog.
A new randomized, double-blind trial evaluated 24 ICU patients with severe ethanol withdrawal.
Group 1: Lorazepam + placebo
Group 2: Lorazepam + dexmedetomidine (doses of 0.4 mcg/kg/hr and 1.2 mcg/kg/hr).
A recent article showed that District of Columbia's Prescription Drug Monitoring program (PDMP) did not change the amount of opioids prescribed after conversion to MMEs (mg morphine equivalents). It is surprising to see a varying effect of PDMPs across the USA. Some have seen dramatic decreases up to 60% in Colorado versus an actual increase of over 50% in Connecticut. Usability, lack of interstate connectivity and quality of information have been seen as rate limiting factors in the efficacy of PDMPs.
PDMPs, by themselves, are not the answer to prescription drug abuse but are an excellent adjunct. Maryland ACEP and a committee chaired by Dr. Suzanne Doyon, Director of the Poison Center, have developed Opioid Prescribing Guidelines and a Discharge pamphlet that can utilized by hospitals to assist with this epidemic. The guidelines and pamphlet have been endorsed by MDPCC, MDACEP, DHMH and a multitude of other Maryland state agencies. I have attached the guidelines.
Background Information:
ACEP has recently revised its 2004 policy on critical issues in the evaluation and management of adult patients with seizures in the emergency department.
Pertinent Study Design and Conclusions:
Bottom Line:
As an alternative to phenytoin or fosphenytoin, valproate may be considered for refractory convulsive status epilepticus if benzodiazepines fail.
University of Maryland Section of Global Emergency Health
Author: Walid Hammad, MB ChB
Antibiotic Timing in Severe Sepsis/Septic Shock
66 year-old female presents with one week of epigastric and right flank pain. Urinalysis was normal. What’s the diagnosis?
Acetaminophen spent much of 2013 being chased by paparazzi and sharing magazine covers with Miley Cyrus. What a fall from stardom after becoming known as the pain reliever “hospitals use most,” and the one, “recommended by pediatricians.” Slogans we know well based on $100 million/year spent on advertising.
Approximately 150 patients a year die from unintentional acetaminophen poisoning averaged over the past 10 years. From 2001 to 2010, annual acetaminophen-related deaths amounted to about twice the number attributed to all other over-the-counter pain relievers combined,
The FDA sets the maximum recommended daily dose of acetaminophen at 4 grams, or eight extra strength acetaminophen tablets.
Ingestion of 150 mg/kg or approximately 10g for a 70 mg individual reaches the toxic threshold for a single ingestion. The toxic threshold decreases in cases of chronic ingestion.
Patients who “unintentionally” overdose have been found to take just over 8g per day (almost double the recommended maximum). This is unlikely due to taking one extra 325mg tablet once or twice.
Before we all go on a mad NSAID prescribing binge, let's all be aware of the dangers, educate our patients and allow Acetaminophen to walk the red carpet again.
Venomous snakes are believed to be everywhere in the United States except Maine, Hawaii, and Alaska. Most snakebites occur from months of April to October since snakes hibernate in the winter. Most bites occur in the extremities (lower > upper). One of the serious clinical manifestation of snakebite is compartment syndrome.
The following are risk factors for the development of increased intracompartmental pressures:
1) Envenomation of small children
2) Envenomation of digits
3) Application of ice or cold packs
4) Delayed use of antivenin
5) Inadequate dosing of antivenin
