UMEM Educational Pearls

Question

65 year-old male with acute pulmonary edema. Ultrasound at the bedside shows this. What's the diagnosis?

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• International guidelines recommend early invasive strategy (<24hrs) for patients with NSTEMI w/high risk factors defined by a GRACE score >140
• A recent meta-analysis based on 7 RCTs & 4 observational studies demonstrated an inconclusive survival benefit with an early invasive strategy 
• Heterogeneity across multiple studies including timing of intervention, definition of MI, patients' risk profiles, major bleeding, and sample size make the interpretation of survival results difficult
• Based on the most recent data the optimal timing of intervention remains unclear and a more definite RCT is warranted to guide clinical practice

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The newest iteration of 'Guidelines for the Early Management of Patients with Acute Ischemic Stroke' was recently published. Here are the key revisions specific to blood pressure management:

• In patients with markedly elevated blood pressure who do not receive fibrinolysis, a reasonable goal is to lower blood pressure by 15% during the first 24 hours after onset of stroke. The level of blood pressure that would mandate such treatment is not known, but consensus exists that medications should be withheld unless the systolic blood pressure is >220 mmHg or the diastolic blood pressure is >120 mmHg (Class I; Level of Evidence C).
• No data are available to guide selection of medications for the lowering of blood pressure in the setting of acute ischemic stroke. Labetalol and/or nicardipine are listed as preferred, but other options can be used (Class IIa; Level of Evidence C).
• Restarting antihypertensive medications is reasonable after the first 24 hours for patients who have preexisting hypertension and are neurologically stable (Class IIa; Level of Evidence B).

If administering rtPA, blood pressure needs to be <185/110 mm Hg. That recommendation didn't change.

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Question

A foley is inserted in a fire victim patient. Urine return is in picture. Describe the reason for this colored urine.

Special Thanks to Dr. Doug Sward for the urine picture 

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Attachments

• 1302281842_Foley-Sward.jpg (4,224 Kb)

Background Information:

Ever wonder what you would do if you were the first on scene after the earthquake in Haiti or in the Superdome as Hurricaine Katrina survivors started to arrive? How could you save the most lives? As is typical of emergency medicine, blood and gore tend to get the most attention, but if you want to save lives you have to think about what is the greatest life threat.  In a large-scale disaster, it turns out, lack of water and abundance of feces kill the most the fastest and need to be addressed first.

The Sphere Project Handbook:

-one of the core documents of humanitarian response

-outlines what should be done to save the most lives in the first days, weeks, and months of a disaster.

-available free online (see reference below)

Pertinent Conclusions: (need-to-know recommendations for the first few days)

-Water: 15L/person/day (any quality--sanitize as per our previous pearl)

-Latrines: max 20 people/latrine, <50m from dwellings, >30m from water sources

       -What kind?

             -First 2-3 days: demarcated defecation area

             -days-2 months: trench latrines (shallow trenches to defecate in)

Other hygeine:

-Solid waste disposal: one 100L refuse container/10 households, emptied at least 2x/week

-Dead bodies: dispose of according to local custom. Generally not an immediate source of infection

-Shelter: >3.5 sq. meters/person of covered floor space

Bottom LIne:

People's need for water and defecation will not stop in a disaster and too little water and too much excrement are the greatest immediate life threats to disaster survivors. Plan to deal with these early to save the most lives.

University of Maryland Section of Global Emergency Health

Author: Andi Tenner, MD, MPH

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Excessive and improper administration of local anesthetic (a.k.a. local anesthetic systemic toxicity or L.A.S.T.) can lead to cardiac toxicity with symptoms ranging from benign arrhythmias to overt cardiac arrest. 

Administration of a 20% intra-lipid emulsion has been experimentally known to reverse L.A.S.T in animal models, but in 2006 the first documented human case of ILE was successfully used during cardiac arrest secondary to L.A.S.T. with hemodynamic recovery and good neurologic outcome. Many case reports have emerged since then, including the use of ILE in toxicity with other lipophilic drugs (e.g., calcium channel blockers, tricyclic antidepressants, etc.)

Several mechanisms have been proposed explaining how ILE works. They include:

• binding circulating toxins in the blood stream, minimizing its exposure to tissues
• improving mitochondrial metabolism (which is inhibited in L.A.S.T.) 
• reducing re-perfusion injury and cellular apoptosis post cardiac-arrest

Dosing of ILE:

• 1.5 mL/kg intravenous bolus of 20% ILE over 2-3 minutes (may be repeated, if necessary) then,
• starting a continuous infusion of 0.25-0.5 mL/kg/min and continuing infusion for 10 minutes after vital signs return.

Check out this video by our own Dr. Bryan Hayes(@PharmERToxGuy) and Lipidrescue.org for more information.

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• Sports are associated w/an increased risk for sudden cardiac death (SCD) in athletes who are affected by cardiovascular conditions predisposing to ventricular arrhythmias (VA)
• SCD has substantially decreased in Veneto Italy due to the introduction of a preparticipation screening program that identifies unrecognized cardiovascular conditions
• This study included 145 athletes evaluated for VA using a screening protocol of ECG, exercise testing, echocardiography, holter monitoring, and cardiac MRI
• ECG was normal in most athletes (>85%)
• VA were detected prevalently during exercise testing 
• Cardiac MRI detected right ventricular regional kinetic abnormalities (ARVD) in 9 of 30 athletes 
• A total of 30% of these athletes had potentially dangerous VA
• In asymptomatic athletes w/prevalently normal ECG, most VA's can be identified by adding an exercise test 

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Just before you upgraded your old computer, recall what happened when you had Excel, Word and PowerPoint all open at the same time. In the concussed state, the brain is essenatially functioning like your old computer... and the more tasks it must perform, the slower it will work and slower it will recover. Hence the concept of cognitive rest. Below is taken from the AMSSM position statement of concussion in sport.

Return to school

There are no standardized guidelines for returning the injured athlete to school. If the athlete develops increased symptoms with cognitive stress, student athletes may require academic accommodations such as a reduced workload, extended test-taking time, days off or a shortened school day.

Some athletes have persistent neurocognitive deficits following a concussion, despite being symptom free. Consideration should be made to withhold an athlete from contact sports if they have not returned to their ‘academic baseline’ following their concussion (level of evidence C).

The CDC developed educational materials for educators and school administrators that are available at no cost and can be obtained via the CDC website. Additional resources for academic accommodations should be developed for both clinicians and educators (level of evidence C).

Adam Friedlander shared the practical application of this which I found amusing:

" I always recommend what Peds neuro called "a brain holiday" - my favorite part.  All of our nurses look at me like I'm nuts, but it is now on our official concussion/CHI DC instructions.  I always say to the kiddo: "You'll love this part.  No homework, no reading."  Then I turn to mom and dad and tell them they'll love the next part: "No TV, no video games."

Thank you for sharing Adam!!

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Luu JL, Wendtland CL, Gross MF, et al. Three percent saline administration during pediatric critical care transport. Ped Emerg Care 2011;27(12):1113-1117

Typical opioid withdrawal include clinical symtpoms of piloerection, nausea, vomiting and diarrhea. If you were to see seizure, another etiology other than opioid withdrawal should be investigated. 

Except in the case of neonates borne to women who have been taking opioids chronically such as a methodone patient. Once the child is born, symptoms of withdrawal may take days to weeks to materialize though seizures typically occur <10 days. The child is at increased risk of SIDS as well.

Japanese Encephalitis

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Managing Traumatic Hemorrhagic Shock

• When managing the critically ill patient with traumatic hemorrhagic shock, the primary objectives are to stop bleeding, maintain tissue perfusion and oxygen delivery, and limit organ dysfunction.
• Pearls to consider when resuscitating these patients include:
  • In the patient without brain injury, target an SBP of 80 - 100 mm Hg until major bleeding has been controlled.
  • Limit aggressive fluid resuscitation
  • Avoid delays in blood and blood component transfusion.  Transfuse early. Though the optimal ratio remains controversial, most transfuse PRBCs and FFP in a 1:1 ratio.
  • Consider point-of-care testing, such as thromboelastography (TEG), to assess the degree of coagulopathy and guide transfusion strategies.
  • Consider the use of tranexamic acid

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Question

68 year-old female presents with stridor and palpable goiter. Here's a clip from CT of the chest. What's the diagnosis?

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• Symptomatic aortic stenosis if left untreated has a high mortality rate (5 yr mortality rate is 50% w/angina, 3 yr mortality rate is 50% w/syncope, and 2 yr mortaltiy rate is 50% w/CHF)
• Standard tx includes medical therapy +/- balloon aortic valvuloplasty
• A recent study comparing standard therapy to transcatheter aortic-valve replacement (TAVR) revealed rates of death at 2 yrs were 68% in standard therapy group vs. 43.3% in TAVR group (p<0.001)
• At 2 yrs the rate of rehospitalization was 72.5% in standard therapy group vs. 35% in TAVR group
• The rate of stroke was higher after TAVR vs. standard therapy in the 1st 30 days
• In appropriate patients with severe AS who are not surgical candidates TAVR reduced rates of death, hospitalizations, and symptoms at 2 yr follow-up

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Most antidotes have not been adequately studied in pregancy and hold a Pregnancy Risk Category 'C' by the FDA. However, there are a few antidotes that hold a category 'D' or 'X' rating (contraindicated).

1. Ethanol (toxic alcohols) - Category C
   • Reproduction studies have not been conducted with alcohol injection. Ethanol crosses the placenta, enters the fetal circulation, and has teratogenic effects in humans. When used as an antidote during the second or third trimester, Fetal Alcohol Syndrome AS is not likely to occur due to the short treatment period; use during the first trimester is controversial.
   • Alternative (preferred) antidote: fomepizole.
2. Methylene blue (methemoglobinemia) - Category X
   • Use during amniocentesis has shown evidence of fetal abnormalities, but it has been used orally without similar adverse events. IV may be ok.
3. Lorazepam and diazepam (seizures, nerve agents) - Category D
   • Teratogenic effects have been observed in some animal studies and in humans. Lorazepam/diazepam and their metabolite cross the human placenta.
4. Potassium iodide (radioactive iodine) - Category D
   • Iodide crosses the placenta (may cause hypothyroidism and goiter in fetus/newborn). Use for protection against thyroid cancer secondary to radioactive iodine exposure is considered acceptable based upon risk:benefit, keeping in mind the dose and duration.
5. Amyl nitrite (cyanide) - Category C (manufacturer contraindicates)
   • Animal reproduction studies have not been conducted. Because amyl nitrate significantly decreases systemic blood pressure and therefore blood flow to the fetus, use is contraindicated in pregnancy (per manufacturer).
   • Other options exist to treat cyanide exposure including sodium nitrite, sodium thiosulfate, and hydroxocobalamin.
6. Penicillamine (chelator) - Category D

In most cases, the benefits of short-term use probably outweigh the risk, especially when accounting for the health and prognosis of the mother.

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-    The most common disease producing enzymopathy in humans

-    Affects 400 million people worldwide

-    Highest prevalence is among persons of African, Asian, and Mediterranean descent

-    Patients can be asymptomatic but may present with symptoms of acute hemolytic anemia, which may be precipitated by certain medications (Oxidative medications) or foods (some types of beans)

-    Avoid oxidative drugs (consult your PharmD when your patient has G6PDd)

-    Diagnosis: Measure the actual enzyme activity of G6PD rather than the amount of the enzyme. A more practical test is the presence of Indirect hyperbilirubinemia, but it is non specific

-    Treatment consists of oxygen and bed rest in minor cases. However, severe cases may require PRBC transfusion

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Propofol is generally a well-tolerated sedative / amnestic but occasionally it can lead to the propofol infusion syndrome (PRIS); a metabolic disorder causing end-organ dysfunction.

Suspect PRIS in patients with increasing lactate levels, worsening metabolic acidosis, worsening renal function, increased triglyceride levels, or creatinine kinase levels. End-organ effects include:

• Myocardial dysfunction / Arrhythmias
• Rhabdomyolysis
• Acute renal failure

The true incidence of PRIS is unknown, however, certain risk factors have been identified:

• Doses >4-5mg/kg/hour
• <18 years of age
• Critically-ill patients; especially receiving vasopressors or steroids
• History of mitochondrial disorders
• Infusions >48 hours

Prevent PRIS by using adequate analgesia (with morphine or fentanyl) post-intubation, which may reduce the overall dosage of propofol ultimately reducing the risk.

If PRIS develops, stop propofol and provide supportive care; IV fluids, ensuring good urine output, adequate oxygenation, dialysis (if indicated), vasopressor and inotropic support.

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Question

A 25 year-old female presents complaining of a "net-like" rash bilaterally on her medial thighs. She denies any pain but states that the rash looks “pretty scary” What's the diagnosis?

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-Common life-threatening cardiovascular effects of cocaine intoxication include tachydysrhythmias, ventricular fibrillation, myocardial ischemia, and infarction.

-Emergency management of acute cocaine intoxication relies mainly on supportive and symptomatic treatment, w/liberal use of gamma-aminobutyric acid receptor agonists such as benzodiazepines.

-Intravenous lipid emulsion (ILE) therapy has been used successfully to treat cardiac toxicity associated with a variety of lipid-soluble drugs, such as local anesthetics, calcium/beta-blockers, tricyclic anti-depressants, and cocaine. 

-The current hypothesis, called the “lipid sink” hypothesis, suggest that ILE infusion creates an expanded lipid phase in the plasma that absorbs the circulating lipophilic toxin and decreases the amount of free unbound toxin available to bind to the myocardium.

-When life-threatening cardiac arrhythmias (e.g. wide-complex tachycardia/prolonged QT) are not amenable to standard therapy (e.g. sodium bicarbonate/magnesium) consider ILE as a potential option to the current algorithm. 

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Estimated 3.8 million sport-related concussions per year (likely significantly higher due to underreporting)

Most patients recover within a 7-10 day period

** Children and teenagers require more time than college and professional athletes

This "accepted" time for recovery is not scientifically established and there is a large degree of variability based on multiple factors including age (as above), sex & history of prior concussions

Approximately 10% of athletes have persistent signs and symptoms beyond 2 weeks (which may represent a prolonged concussion or the development of post-concussion syndrome)

During this time the patient should have complete rest from all athletic activities, close follow-up with PCP and be educated re concussions.

If practical, "cognitive rest" should also be prescribed. This is one of the most frequently neglected aspects of post-concussion care and will be discussed in a future pearl.