UMEM Educational Pearls

The seasonal influenza vaccine is produced in chicken eggs. Ovalbumin, an egg protein, is often listed as a component of the purified vaccine on most drug-package inserts. The concentration of ovalbumin indicates the potential egg-allergen content of a vaccine.

Earlier ACIP guidelines recommended against giving the influenza vaccine to people with egg allergy, including those with a history of mild symptoms. However, several studies showed that influenza vaccine containing inactivated, or killed, virus is safe to give to people with egg allergy, especially those with a history of mild allergic reactions.

Influenza vaccines are now made with much lower ovalbumin concentrations than in the past; therefore, the level of potential egg protein allergens in a single dose of vaccine is extremely low.

The following are ACIP recommendations for the 2011 to 2012 influenza season:

• Inactivated influenza vaccine (seasonal flu shot) is safe to give to people whose history of allergic reactions to egg has been limited to hives.
• People with more severe allergic reactions to egg may receive the seasonal flu shot, but the vaccine must be given by a healthcare professional familiar with the signs and symptoms of an allergic reaction to egg and who has the ability to treat a severe reaction if one occurs.

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• Sulfonyurea overdose is associated with hypoglycemia, which may be delayed and prolonged.
• Treatment with dextrose results in hyperglycemia, which potentiates insulin release from the pancreas, resulting in recurrent hypoglycemia.
• Octreotide mimics somatostatin, which suppresses the secretion of glucagon and insulin, among others.
• Octreotide binds with somatostatin receptors, closing calcium channels, preventing the influx of calcium and subsequent insulin release.
• The dose is 100 mcg SUBCUTANEOUSLY, repeated every 8 hours as needed.

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Ventricular assist devices (VAD) pump blood from the left, right or both ventricles for patients in severe ventricular failure.

VADs may be placed temporarily (as a bridge to transplant) or permanently in patients who are not transplant candidates (also known as Destination Therapy)

Certain types of VADs continuously pump blood in a non-pulsatile fashion. In these cases, a patient may be perfusing normally without a palpable pulse.

Familiarity with potential VAD complications is important as a patient with a VAD may be presenting to an ED near you. Complications include:

• Bleeding complications from anticoagulation; all VADs require some form of anticoagulation
• Infection; a portion of the VAD exits externally and this site can be a portal of entry for skin flora
• Embolic phenomenon from clots generated within the VAD
• Infection of the VAD itself, called VAD-itis; this can also lead to sepsis

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Question

24 year-old male presents following fall from a scaffolding and complains of wrist pain. Diagnosis?

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Quick pearls on cardiogenic shock

Post-MI cardiogenic shock is associated with a mortality of 50-70%. There are only a few interventions that have been demonstrated to improve outcomes: early use of intra-aortic balloon pump, stenting, and G2B3A inhibitors.

It is generally recommended to avoid clopidogrel since so many of these patients will require CABG.

Early use of mechanical ventilation decreases work of breathing and improves oxygenation.

Remember that age alone is not a contraindication to aggressive treatment.
 

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Severs disease

- Perhaps the most common overuse injury

-Pain is due to inflammation of the calcaneal apophysis growth plate

- Caused by repetitive microtrauma from the pull of the Achilles tendon on the apophysis.

- Occurs in young athletes ages 7-14

Sx’s bilateral in >50%

Hx – Gradual onset of posterior heel pain, worse with activity, better with rest.

PE – Tenderness at the insertion of the Achilles tendon onto the calcaneous. Swelling is mild.

This is a self limited condition because as the adolescent ages, the physis closes

Tx – Rest (no running or jumping), ice, NSAIDs, heel lifts/arch supports. Outpatient physical therapy for stretching and strengthening exercises.

You have seen the study comparing diazepam to lorazepam IV for the cessation of seizures. Lorazepam one that one. Now, for prehospital status epilepticus midazolam IM went head to head with IV lorazepam to see which would stop seizure more quickly.

This study was more about the practicality of starting an IV than it was of the pharmacokinetics or onset of action of a particular benzodiazepine. It was a large enough study to warrant publication in New Engl J Med last month and is worth noting.

Subjects whose seizures ceased before ED arrival (median):

Time to active treatment: 1.2 min IM Midazolam group;  4.8 min IV Lorazepam group

Median times active treatment to cessation of SZ:  3.3 min IM Midazolam and 1.6 min IV Lorazepam

Safety was equal in both groups. This study validates EMS initiating therapy with IM midazolam for the cessation of seizures while intravenous access is being attempted. 

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Ice-Cold Crystalloid for Therapeutic Hypothermia

• Therapeutic hypothermia (TH) is a critical component in the care of patients with ROSC from out-of-hospital cardiac arrest.
• Despite recent guidelines, initiation of TH in the ED for appropriate patients remains less than optimal.
• Reported barriers to the induction of TH in the ED include lack of familiarity, lack of collaboration with the ICU, access to special equipment, and the logistics of cooling.
• A recent analysis of studies on the use of ice-cold crystalloids (ICC) found that an infusion of 4⁰ C fluid is a safe, effective, inexpensive, and readily available method for inducing TH.
• Importantly, no study reported any significant hemodynamic complication (i.e. CHF) from the use of ICC.
• Lastly, once the target temperature has been reached, ICC alone cannot maintain TH.  Additional methods, such as surface cooling blankets or ice packs, should be used.

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Morton's Neuroma

1. A benign perineural fibroma of an intermetatarsal plantar nerve.
2. Most commonly affects the third and fourth intermetatarsal space
3. Patient's will often complain of pain and/or numbness in the ball of their foot and toes when the metatarsal heads are compressed together as in when wearing shoes. Pain is often described as burning or shooting.  Some patients report that it feels like they are standing on a pebble.
4. On physical exam you can reproduce the pain by squeezing the metatarsal heads together. (Mulder's sign)
5. Diagnosis can be confirmed with MRI though clearly this does not need to be done in the ED.
6. Treatment includes NSAIDs and referral for orthotics, corticosteroid injection, or surgical removal.

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Children & Appendicitis 

• Vomiting may be the first sign. 
• Children may not experience anorexia and may actually request food. 
• Most young children have perforation at the time of diagnosis.
• Children younger than 2 years of age may have generalized symptoms such as irritability and tachypnea. 
• Ultrasonography is useful in evaluation of thin children but is very operator dependent.
• CT with oral contrast and i.v. contrast may be needed to differentiate intraabdominal structures in thin children

A fluid bolus is often the first-line therapy for patients with pericardial tamponade. A fluid bolus, however,  may not always improve hemodynamics.

The cardiac index of forty-nine patients with cardiac tamponade was assessed before and after a 500 cc normal saline bolus:

• 47% increased their cardiac index
• 22% did not demonstrate a change
• 31% decreased their cardiac index

Bottom-line: A fluid bolus may a reasonable first choice in a hypotensive patient with tamponade, but remember that fluid boluses may not always work. Attempts at fluid resuscitation should never delay definitive treatment with pericardiocentesis.

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Question

35 year old male with sudden onset of abdominal pain. Diagnosis?

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You might think that patients with painless MIs might have a better prognosis than patients with pain. Unfortunately, this is just not true. A recent study (1) supported prior literature indicating that the lack of pain is not a predictor of a more benign course, and in fact patients with painless MIs have a higher in-hospital and 1-year mortality. There are several other factors that may associate lack of pain with worse outcomes (e.g. painless MIs occur more often in older patients), but regardless it's important to remember that (1) many patients with MI will present without pain, and (2) the lack of "typical" symptoms should not be reassuring.

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Common herbs and supplements used to treat pain

1) Turmeric root - used for arthritis pain. Little evidence to support its use. May slow blood clotting/enhance anticoagulant/antiplatelet effects.

2) Boswellia - used for OA and RA pain. Little evidence to support its use.May interfere with anticoagulant drugs and leukotreine inhibitors.

3) St. John's Wort - used for HA, migraine, neuralgia, muscle pain, sciatica, fibromyalgia. Little to no evidence to support its use.May interfere with numerous medications including anticoagulants, digoxin and SZ medications.

4) Glucosamine and Chondroitin - used for OA, knee pain, back pain. The glucosamine/chondroitin arthritis intervention trial found that "the dietary supplements Glucosamine and Chondroitin, taken alone or in combination are generally ineffective for OA pain of the knee." May increase the effect of Warfarin.

5) KavaKava - used for HA, muscle pain. Insufficient evidence demonstrating effectiveness for treatment of painful conditions. May cause severe liver damage and potentiate drowsiness side effects of other medications.

6) Echinacea - used for pain, migraines, arthritis. Little evidence to support its use. May exacerbate symptoms of autoimmune disorders.

7) Valerian root – used for joint and muscle pain. Insufficient evidence to support its use. May potentiate sedative side effects of barbiturates and benzos.

8) Chinese Thunder God Vine – used for arthritis. There is some evidence to suggest that this agent has anti-inflammatory properties. Long term this agent may decrease bone mineral density in women, decrease fertility in men, and may produce GI side effects.

9) Feverfew – used for muscle pain, arthritis. Some evidence to suggest that may reduce frequency of migraine headaches. No evidence for benefit in RA. May enhance effects of anticoagulants and some drugs that undergo hepatic metabolism.

10) Cat’s claw – used for herpes zoster, bone pain, arthritis. Possible benefit for OA and RA in small studies in humans but no large study has shown benefit. May interact with clotting agents, BP meds and cyclosporine.

11) Black Cohosh – used for muscle pain and arthritis. Insufficient evidence demonstrating benefit. May be associated with severe liver side effects.

12) Bromelain – used for muscle pain, arthritis, knee pain. The NIH reports that bromelain may be effective for arthritis when used in combination with trypsin and rutin. May interact with amoxicillin and other antibiotics, anticoagulants and antiplatelet drugs.

13) Devil’s claw – used for muscle pain, back pain, arthritis, migraine. The NIH reports that “taking devil’s claw alone or with NSAIDs seems to help decrease OA related pain.” May increase effects of warfarin.

• diagnosis of exclusion
• bilateral leg pain only in the evening/night
• should NOT have a limp, pain, or symptoms during the day
• completely normal physical exam
• no systemic symptoms, localizing signs, joint involvement, or limitation of activity
• look for something else if there is anything wrong on review of systems, examination, or imaging studies

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• Drug rash with eosinophilia and systemic symptoms (DRESS) syndrome, previously named “anticonvulsant hypersensitivity syndrome,” is a severe adverse drug reaction which occurs in approximately 1 of every 1,000–10,000 uses of anticonvulsants.

• Characterized by triad of fever, rash, and internal organ involvement.

• Usually involves aromatic anticonvulsants such as phenytoin, carbamazepine, phenobarbital, primidone, lamotrigine, and possibly oxcarbazepine.

• DRESS occurs most frequently within the first 2 months of therapy and is not related to dose or serum concentration.

• Treatment includes prompt discontinuation of the offending agent. Patients should be admitted to the hospital and receive methylprednisolone 0.5–1 mg/kg/d divided in four doses. Other promising therapies include use of IVIG.

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ECMO for ARDS and Refractory Hypoxemia

• Extracorporeal membrane oxygenation (ECMO), or extracorporeal life support (ECLS), is increasingly being used for a variety of cardiac and pulmonary conditions.
• Venovenous ECMO (VVE) should be considered in the treatment of patients with profound gas-exchange abnormalities that are refractory to accepted standards in ventilator management.
• Although indications vary slightly by institution, general indications for VVE include:
  • Severe hypoxemia: P_aO₂/F_iO₂ < 80 despite high levels of PEEP for at least 6 hours
  • Uncompensated hypercapnia with pH < 7.15
  • Excessively high plateau pressures (> 45 cm H₂0)

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Question

28 y.o. male felt his left knee "pop" after landing from a jump while playing basketball. Knee exam revealed limited knee extension. X-ray is shown. Diagnosis?

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