UMEM Educational Pearls

Title: Diarrheal Disease Outbreak in the US

Category: International EM

Keywords: cyclospora, outbreak, international, tropical, infectious disease (PubMed Search)

Posted: 7/31/2013 by Andrea Tenner, MD
Click here to contact Andrea Tenner, MD

General Information:

As of July 30th, 2013, there have been 378 cases of Cyclospora  infection from multiple states in the US.  Cyclospora is most common in tropical and sub-tropical regions, and is spread via fecal-oral route.  While the cause of the most recent outbreak is unknown, outbreaks in the US are generally foodborne.

Clinical Presentation:

- Symptoms usually begin 7 days after exposure

- Watery diarrhea, cramping, bloating, nausea, fatigue, increased gas, vomiting, low grade temperature

- Can persist several weeks to > 1 month

Diagnosis:

- Concentrated Stool Ova and Parasites— viewed under modified acid fast or fluorescence microscopy (labs can submit photos to the CDC for “telediagnosis”)

Treatment:

- TMP-SMX DS one tab po bid x7-10 days

- No effective alternate for failed treatment or sulfa allergy

- Most will recover without treatment but S/S can persist for weeks to months

Bottom Line:

Consider Cyclospora as a cause of prolonged diarrheal illness, treat with TMP-SMX.

University of Maryland Section of Global Emergency Health

Author: Andi Tenner, MD, MPH

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Question

Elderly patient who originally presented for severe pancreatitis now intubated for worsening hypoxemia. CXR is shown below, what's the diagnosis?  

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Question

13 year-old female fell on right shoulder while catching a rebound during a basketball game. The patient is holding her arm in adduction and has exquisite scapular tenderness on exam. What’s the next step in management? …oh, and what’s the diagnosis?

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Tight glycemic control (HbA1C<7%) has previously been recommended in CAD based on data from the United Kingdom Prospective Diabetes Study (UKPDS)

A recent study (JACC) evaluated the relationship between glycemic control, cardiovascular disease (CVD) risk, and all-cause mortality 

Patients with a mean HbA1C 7-7.4% were compared to those with mean HbA1C <6%; tight glycemic control had a 68% increased risk of CVD hospitalization

Lenient HbA1C>8.5% also had significantly higher risk

CVD risk and all-cause mortality is greater with both aggressive and lax glycemic control and the optimal reference range may lie between 7-7.4%

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Title: Dupuytren Disease

Category: Orthopedics

Keywords: Hand nodules, contactures (PubMed Search)

Posted: 7/28/2013 by Brian Corwell, MD (Updated: 7/29/2025)
Click here to contact Brian Corwell, MD

Dupuytren disease is a nodular thickening and resultant contraction of the palmer fascia.

Increased in those of Northern European dissent.

One or more painful nodules located near the distal palmer crease.

Over time may result in flexion at the MCP joint.

Most commonly affects the ring finger.

Sensation is normal.

Over time affects ADLs

Tx: night splints and surgery



Title: Intranasal fentanyl (submitted by Ari Kestler, MD)

Category: Pediatrics

Keywords: sedation, pain management (PubMed Search)

Posted: 7/3/2013 by Mimi Lu, MD (Updated: 7/26/2013)
Click here to contact Mimi Lu, MD

Cringing at the thought of sewing up another screaming 2 year old?

Consider intranasal fentanyl.

Who: Young, otherwise healthy pediatric patients undergoing minor procedures (laceration repair, fracture reduction/splinting, etc...)

What: Fentanyl (2mcg/kg)

When: 5 minutes pre-procedure

Where: Intranasal

Why: More effective than PO, less invasive than IV while being equally efficacious.

How: Use an atomizer, splitting the dose between each nostril.

 

References:
1) Use of Intranasal Fentanyl for the Relief of Pediatric Orthopedic Trauma Pain, Mary Saunders, MD Academic Emergency Medicine 2010, 17:1155-1161.
2) A Randomized Controlled Trial Comparing Intranasal Fentanyl to Intravenous Morphine for Managing Acute Pain in children in the Emergency Department, Meredith Borland, MBBS, FACEM, Annals of Emergency Medicine, March 2007, Vol. 49, No.3, 335-340
3) The Implementation of Intranasal Fentanyl for Children in a Mixed Adult and Pediatric Emergency
Department Reduces time to analgesic Administration, Anna Holdgate, MBBS, Academic Emergency Medicine 2010, 17:214-217.


General Information:

       ·   Caused by the ameboflagellate Naegleria Fowleri

       ·   Case fatality rate is estimated at 98%

       ·   Commonly found in warm freshwater environments such as hot springs, lakes, natural mineral             water, especially during hot summer months

       ·   Incubation period 2-15 days

Relevance to the EM Physician:

·      Clinical presentation: resembling bacterial meningitis/encephalitis

·      Final diagnostic confirmation is not achieved until trophozoites are isolated and identified from CSF or brain tissue

·      Treatment: Amphotericin B

Bottom Line:

·      History of travel to tropical areas or exposure to warm or under-chlorinated water during summer time should raise the suspicion for Naegleria Fowleri. The amoeba is not sensitive to the standard meningitis/encephalitis therapy and amphotericin B must be added to the treatment regimen.

 

University of Maryland Section of Global Emergency Health

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HIV, ART, and the ICU

  • Though survival has dramatically improved for patients with HIV, there has been no decrease in the quantity of ICU admissions for this select patient population.
  • One of the most common reasons for ICU admission is now adverse effects of antiretroviral therapy (ART).
  • When managing a critically ill HIV patient in the ED or ICU, consider the following effects of ART as an etiology:
    • Lactic acidosis
      • Seen with nucleoside reverse transcriptase inhibitors (NRTIs): greatest risk with didanosine, stavudine, and zidovudine
      • Presentation: fatigue, malaise, vomiting, abdominal pain, hepatomegaly
      • Lactate often > 10 mmol/L
    • Abacavir hypersensitivity
      • Usually within first 6 weeks of drug initiation
      • Presentation: rash, fever, shortness of breath, vomiting, abdominal pain
      • Can rapidly progress to cardiovascular collapse

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Question

A 3 year-old boy was attacked by a dog and sustained the injury below. Name one injury that should be strongly considered (Hint: there are several)

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  • A recent meta–analysis of 12 studies (6,538 patients with 1,824 ROSC) assessed the quality of cardiopulmonary resuscitation (CPR) using either manual vs. mechanical (load-distributing or piston-driven) compressions in out-of-hospital cardiac arrest
  • Compared w/manual CPR, load-distributing band CPR had significantly greater odds of ROSC (odds ratio, 1.62 and p<0.001)
  • The treatment effect for piston-driven CPR was similar to manual CPR
  • The difference in percentages of ROSC rates from CPR was 8.3% for load-distributing band CPR and 5.2% for piston-driven CPR
  • Compared with manual CPR, combining both mechanical CPR devices produced a significant treatment effect in favor of higher odds of ROSC with mechanical CPR devices (odds ratio, 1.53 and p<0.001)

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Title: Treatment of Severe Hypothyroidism

Category: Endocrine

Keywords: Hypothyroidism, treatment (PubMed Search)

Posted: 7/20/2013 by Michael Bond, MD (Updated: 7/29/2025)
Click here to contact Michael Bond, MD

Treatment of Severe Hypothyroidism

We do not see patient's with severe hypothyroidism often, but it is important that they be treated aggressively. Some treatment pearls are

  • Rule out aggravating cause (i.e.: infection [UTI, pneumonia], myocardial infarction)
  • Start IV levothyroxine dosing
    • Initial dose 400-500 mcg. This is a large dose but it only saturates the thyroid receptors and will not cause a rebound hyperthyroidism state.
    • Daily dose 100 mcg/day
  • Consider starting Dexamethasone/hydrocortisone
    • Patients may also have adrenal insufficiency from primary pituitary failure or may have secondary adrenal suppression due to the severe hypothyroidism.  If dexamethasone/hydrocortisone is not provided they may develop severe adrenal insufficiency once you kick start their metabolism.

 



Lactate is commonly used in the adult ED when evaluating septic patients, but there is a lack of literature validating its use in the pediatric ED.  Pediatric studies have suggested that in the ICU population, elevated lactate is a predictor of mortality and may be the earliest marker of death.
 
A retrospective chart review over a 1 year period showed that one elevated serum lactate correlated with increased pulse, respiratory rate, white blood cell count and platelets.  Serum lactate had a negative correlation with BUN, serum bicarbinate and age.  Elevated lactate levels were higher for admitted patients. However, the mean serum lacate level was not statistically different between those diagnosed with sepsis and those that were not.
 
The study included 289 patients less then 18 years who had both blood cultures and lactate drawn.  This community hospital had a sepsis protocol in place that automatically ordered a lactate with blood cultures.  Only previously healthy children were included.
 
The study is limited by its small sample size and overall low lactate levels.  Despite having a protocol in place, only 39% of patients who had blood cultures drawn had lactate levels available for analysis.  The mean serum lacate in this study was 2.04 mM indicating that the study population may not have been sick enough to determine mortality implications.  There were no serial measurements.

 
Bottom line:  Consider measuring serum lacate in your pediatric patient with suspected sepsis.  Pediatric ICU literature does suggest that an serum lactate as low as 3mM is associated with an increased mortality in the ICU.

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Title: Tihkal - What does that mean

Category: Toxicology

Keywords: lsd, alpha-methyltryptamine, AMT (PubMed Search)

Posted: 7/18/2013 by Fermin Barrueto (Updated: 7/29/2025)
Click here to contact Fermin Barrueto

The internet has become a wealth of information and some books have now gained internet noteriety. A chemist and author of the book - TIKHAL: Tryptamines I Have Known and Loved is an excellent example. 

Tryptamines include drugs like LSD and alpha-methyltryptamine (AMT). Vivid visual hallucinations and serotonin agonism, these drugs were glamorized by this author. He would synthesize a tryptamine and then "taste it". Take a look at the link below where he first describes the biochemical synthesis he performed then describes his dose response effect when he tried the drug.

If you run into a drug or slang term in the ED you are not familiar with, the website www.erowid.org will likely have the translation. 

http://www.erowid.org/library/books_online/tihkal/tihkal48.shtml



COPD treatment guidelines (e.g., GOLD) recommend 10-14 days of steroid therapy following a COPD exacerbation to prevent recurrences; the supporting data is weak.

A recent noninferiority trial (here) compared patients with a severe COPD exacerbation who received either a 5-day course (n=156) or 14-day course (n=155) of prednisone 40mg.

The results were:

  • No significant reduction in time until the next exacerbation (primary end-point)
  • No significant difference in mortality, incidence of mechanical ventilation, FEV1, or dyspnea scores (secondary end-points)

What you need to know:

  • This was a non-inferiority trial, which has limitations
  • All subjects received broad-spectrum antibiotics and an initial dose of IV steroid
  • Surprisingly, there were no differences between groups with respect to steroid complications (e.g., hyperglycemia, hypertension, etc.)

Bottom-line: 5 days of prednisone may be as effective as 14-days for COPD exacerbations.

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Question

46 year-old female presents with a headache. The following is seen on visual inspection of the eye. What's the diagnosis?

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Radiation therapy is frequently utilized in the management of numerous thoracic malignancies

Cardiovascular disease is now the leading cause of nonmalignancy death in radiation-treated cancer survivors

The spectrum of radiation-induced cardiac disease is broad

The relative risk of CAD, CHF, pericardial/valvular disease, and conduction abnormalities is particularly increased

Early identification of potential cardiac complications w/cardiac MR and echocardiography provides an opportunity for regular assessment and potentially improved long term mortality

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Title: Froments Sign

Category: Orthopedics

Keywords: ulnar nerve, entrapment (PubMed Search)

Posted: 7/13/2013 by Brian Corwell, MD (Updated: 7/29/2025)
Click here to contact Brian Corwell, MD

Tests for distal ulnar nerve entrapment

Ask patient to hold a piece of paper between the thumb and the index finger

Normally this is a fairly simple task.

With an unlar nerve palsy, the patient will substitute with the FPL (flexor pollicis longus - median nerve innervation). This causes flexion of the thumb in order to maintain the grip since the adductor pollicis cannot be used. This causes thumb flexion rather than extension.

 

http://www.mims.com/resources/drugs/common/CP0042.gif

http://www.youtube.com/watch?v=yJTIhm1VfSI



Title: Pediatric Appendicitis Score

Category: Pediatrics

Posted: 7/12/2013 by Rose Chasm, MD (Updated: 7/29/2025)
Click here to contact Rose Chasm, MD

Risk stratisfication score introducted by Maden Samuel in 2002.

The Pediatric Appendicitis Score had a sensitivity of 1, speciificity of 0.92, positive predictive value of 0.96, and negative predictive value of 0.99

Signs:

  • Right lower quadrant tenderness = 2 points
  • Cough/Percussion/Hop RLQ tenderness = 1 point
  • Pyrexia = 1 point

Symptoms:

  • RLQ migration of pain = 1 point
  • Anorexia = 1 point
  • Nausea/Vomiting = 1 point

Laboratory Values:

  • Leukocytosis = 2 points
  • Polymorphonuclear neutrophiia = 1 point

Scores of 4 or less are least likely to have acute appendicitis, while scores of 8 or more are most likely.

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Title: Highlights from the new Salicylate Toxicity Management Guideline

Category: Toxicology

Keywords: salicylate, aspirin, toxicity, sodium bicarbonate (PubMed Search)

Posted: 7/10/2013 by Bryan Hayes, PharmD (Updated: 7/11/2013)
Click here to contact Bryan Hayes, PharmD

In June 2013 the American College of Medical Toxicology (ACMT) released a Guidance Document on the Management Priorities in Salicylate Toxicity. Here are some key highlights:

  • Continuous IV infusion of sodium bicarbonate is indicated even in the presence of mild alkalemia from the early respiratory alkalosis.
  • Euvolemia is important.
  • If intubation is required, administration of sodium bicarbonate by IV bolus at the time of intubation in a sufficient quantity to maintain a blood pH of 7.45-7.5 over the next 30 minutes is a reasonable management option during this critical juncture.
  • Once airway control has been established, it is imperative that the increased minute ventilation and low PCO2 usually seen with salicylate intoxication are maintained.
  • A salicylate concentration approaching 100 mg/dL warrants consideration of hemodialysis in the acute toxicity setting (40 mg/dL for chronic toxicity). Consult nephrology well before these threshold levels.

The full document can be accessed here.

The Poison Review blog by Dr. Leon Gussow discusses the guidance document here.

Follow me on Twitter (@PharmERToxGuy) 



Question

3 year-old male develops rash 5 days after starting amoxicillin for acute otitis media. What's the diagnosis? 

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