UMEM Educational Pearls

Valproic Acid in Status Epilepticus

• In previous pearls, we have discussed the treatment of status epilepticus (SE) with first-line (benzodiazepines) and second-line agents (phenytoin/fosphenytoin).
• Refractory SE is defined as the failure to respond to both first- or second-line antiepileptic medications.
• Valproic acid is listed in many algorithms as a third-line agent for treating SE.
• Avoid valproic acid in refractory SE patients who have hepatic disease or dysfunction.
• Although rare, valproic acid can cause a fatal hepatotoxicity in these patients. 

Show References

Well, there may finally be a replacement for patients with atrial fibrillation who take warfarin (Coumadin).

In late 2010, the FDA approved the drug Dabigatran (Pradaxa) for use in patients with atrial fibrillation.

Dabigatran is an oral direct thrombin inhibitor that has been approved for stroke prevention in patients with A Fib. The drug does not need monitoring like warfarin, and has been deemed to be safer than warfarin.

Be on the lookout for Dabigatran...

Show References

Bretylium was touted for many years as the drug of choice for patients with ventricular dysrhythmias in the setting of hypothermia...in fact it still is recommended by some. Bretylium was actually touted to be effective based on animal studies in which the dogs were PRE-treated with bretylium and then hypothermia was induced. It was found that dogs that were pretreated had fewer episodes of ventricular fibrillation than dogs that were not pretreated. On the other hand, if bretylium was used as a treatment for VFib rather than a prophylactic, it was ineffective. The bottom line....don't bother with bretylium.

Iliotibial band syndrome (ITBS)

• Due to recurrent friction of the iliotibial band (ITB) sliding over the lateral femoral condyle.


http://footcarexpress.com/foot-orthotics/wp-content/uploads/2009/01/iliotibial-band-syndrome.jpg


Hx -

• Sharp or burning pain on the lateral aspect of the knee usually in runners.

• Rarely occurs at start of run, rather, occurs after reproducible time or distance
• (especially when running downhill)


PE-

• Typically negative other than local tenderness (approx. 2cm above lateral joint line) & occasional swelling over the distal ITB.
• 
Specialized tests: See also Ober's test and Noble's test

• 
http://www.youtube.com/watch?v=A0C0WBw4l4s

• http://www.youtube.com/watch?v=IIJVbf_t_2A


Tx

• Most patients respond to conservative treatment involving NSAIDs, stretching of the iliotibial band, strengthening of the gluteus medius, and altering training regimens.

Show References

• Parkinson's Disease is a degenerative disorder of the central nervous system characterized by tremor and impaired muscular coordination due to deficient levels of intra-cerebral dopamine.
• Many of these patients experience motor fluctuations which consists of periods of being "on," which is when they experience a good or hyper response to their medication, and periods of being "off," which is when the parkinson's condition itself is exacerbated.  Differentiating between these two modes is important in terms of managment, but may be challenging.  
• "On time" typically presents with relatively normal or dyskinetic involuntary  ballistic movements, chorea, dystonia, or myoclonus.  These episodes are best treated by avoiding levodopa, carefully administering low-dose benzodiazepines, or perhaps amantadine(possibly effective).
• "Off time"typically presents with sometimes painful dystonia, intorsion of limbs, spasm, and stiffness, and often relates to a period wherein the effects of parkinson's medications such as levodopa are wearing off.   These episodes are best treated by gradually increasing dopamine agonist medication such as bromocriptine, pramipexole, and ropinirole, and likely admission to the hospital. 

Show References

Show References

Boxer's (or Brawler's) Fracture

• Fifth metacarpal neck fracture, usually secondary to a direct blow or closed-fist impact.
• Potentially an unstable fracture and difficult to maintain reduction due to tension from tendons and muscles in the hand.
• Up to forty degrees of angulation can be tolerated without repair, although there is potential for reduced hand function without repair. Any rotational deformity, however, must be corrected.
• Non-displaced fractures: RICE therapy, gutter splint, and Ortho follow-up.
• Displaced, rotated, or angulated fractures (>40 degrees): closed reduction may be attempted but surgical fixation usually required.

Show References

Up to 30-40% of patients with infective endocarditis have neurological symptoms as a result of embolization. This is a good reminder of the frequency of embolization, and also that infective endocarditis should always be part of the differential when you are evaluating a patient with fever + neurological abnormalities.

Show References

FARES Method for Reduction of Anterior Shoulder Dislocations.

This method that was recently highlighted in a publication had a ~78% success rate with the authors able to reduce the shoulder in an average of 2.36 ±1.24 minutes  without having to give the patients any analgesics or sedatives. The technique is done by:

• Placing the patient in the supine position.
• Hold the hand of the affected arm while the arm is at the patient’s side with the elbow extended and the forearm in neutral position.  
• Apply gentle longitudinal traction and slowly move the arm into abduction while oscillating the forearm with continuous, brief (two to three full cycles per second) and short range (approximately 5 cm above and beneath the horizontal plane) vertical  movements of the arm.  These oscillations should be done during all   all stages of the reduction as it helps that patient relax their muscles.
• Once the arm is abducted past 90º, gently externally rotate the arm while continuing to abduct it.  Continue the oscillations.
• Reduction is usually achieved at ~ 120º of abduction.  
• Once reduction is achieved, move the arm gently until it is internally rotated and resting on the patients chest.

Consider trying this with your next shoulder dislocation.  No single method of reduciton is 100% successful, but methods like this that only require a single provider and do not require analgesics are extremely helpful in improving patient flow as they do not utilize a lot of ED resources..

Show References

The Rumack-Matthew nomogram is a well studied and validated tool to help assess the potential for liver toxicity following acute acetaminophen poisoning.  Here is a brief review of when it is best utilized.

• Prior to 4 hours post-ingestion: Not helpful to determine likelihood for toxicity.  Only use is to confirm an ingestion took place.
• Between 4 and 24 hours post-ingestion: Plot the patient's level vs. time after ingestion.  If above the toxicity line, treat with acetylcysteine.
• More than 24 hours post-ingestion: Any elevated acetaminophen level is toxic and should be treated with acetylcysteine.

Outside-the-box situations:

• Chronic exposures: Nomogram not indicated.
• Overdoses with co-ingestants that slow GI motility (e.g., opioids, diphenhydramine) OR extended release products (e.g., Tylenol Arthritis): If the level at 4 hours post-ingestion is not toxic, repeat it at 8 hours post-ingestion.  If either level is toxic, treat with acetylcysteine.

Show References

• Using the neurological examination to test coordination primarily assesses cerebellar function.
• The cerebellum is important for motor learning and timing of motor activity.  It fine-tunes agonist and antagonistic forces of muscle activity, simultaneously and sequentially, across multiple joints which results in smooth and purposeful movements.
• Cerebellar dysfunction causes deterioration of movements, with subsequent under-shooting and over-shooting of purposeful movement, also known as dysmetria.
• Deterioration of movement and dysmetria are precursors to the development of ataxia.

Show References

Dexmedetomidine for Sedation in Acute Neurologic Disease

• Critically Ill patients with acute neurologic disease are managed daily in the ED.
• Due to the need for frequent neurologic assessments, these patients can be challenging should they require sedation.
• Dexmedetomidine, a selective alpha-2 adrenergic receptor agonist, has emerged as an alternative to traditional sedatives (i.e. opioids and benzodiazepines).
• Dexmedetomidine provides sedation and anxiolysis, while producing little effect on level of arousal and cognitive function.  In essence, it reduces discomfort while permitting the patient to arouse for a neurologic examination.
   

Show References

FILE RESEND. This was tested via email and will hopefully work. I apologize for errors - Dlemkin (webmaster)

What is the diagnosis? (DON'T LOOK DOWN AT THE ANSWER)

50 year-old male prisoner s/p assault, + LOC

CT shows right-sided traumatic subarachnoid hemorrhage

Show References

Therapeutic hypothermia is generally accepted as a useful intervention that should be employed in patients that are resuscitated after cardiac arrest. Many protocols for cooling are relatively complicated, involving endovascular catheters, cooling blankets, cooling helmets, or other devices that are expensive and not widely available. The cooling process can actually be fairly simple, however, with ice and cool IV fluids. The most recent study that demonstrated this used nothing more than application of ice to the groin, neck, and axillae; and administration of 4^o C IVF infused at 30cc/kg at 100ml/min via two peripheral catheters. Sedation or paralysis + intubation was used as per the norm.

Patients receiving this simple intervention were able to achieve goal temperature of 32^o-34^o C within 3-4 hours, and hypothermia was maintained for a full 24 hours before rewarming.

The study shows that expensive equipment and complicated protocols are not necessary for therapeutic hypothermia.

Show References

                Involves an avulsion of the flexor digitorum profundus  (FDP) tendon from its insertion on the distal phalanx.

     Ring finger is most commonly involved.

                Usually occurs from a grabbing attempt (resulting in forced DIP extension during maximal FDP contraction) as would occur while attempting to grab someone’s jersey such as in football or rugby.

Clinically, there is normal passive DIP ROM with loss of active flexion. Examine this by asking the patient to flex the fingertip at the DIP while the PIP joint is held in extension.

*Remember that patients with a 90% full-thickness tendon laceration may still have normal (albeit painful) range of motion. The examiner must evaluation the strength of the tendon against resistance. This injury is commonly missed as it is diagnosed as a “jammed” finger.

Plain films may show a bony avulsion, but are often negative.

Treatment is primary repair especially with large bony fragments. Partial ruptures can be treated nonoperatively at the discretion of the hand surgeon.

Show References

Hyponatremic seizures are a frightening entity.  Anticonvulsants don't work well, and will likely cause apnea well before they halt the seizure.  Hypertonic saline carries with it the fear of inducing central pontine myelinolysis (CPM) with overly rapid correction of the hyponatremia.  

However:

• CPM usually occurs at sodium level corrections of >8 mEq/L/day
• Hyponatremic seizures are usually stopped with a correction of only 3-5 mEq/L

So, you can safely correct hyponatremia rapidly in the setting of seizures. Do it like this:

Give 2-3 mL/kg of 3% NaCl in rapid sequential boluses, until seizures stop.  A theoretical maximum dose is 100mL/kg, but recall that only a relatively small correction is required to stop the seizure.  

After you've stopped the seizure, correct the hyponatremia slowly, as you would otherwise.

Show References

• Vitamin K can be used intravenously for management of the NON bleeding patient with a high INR (>9).
• Although anaphylactoid reactions have been described, most cases occurred with large doses of vitamin K, administered rapidly, and with little dilution.
• It is estimated that the incidence of anaphylaxis is 3:10,000 doses.
• The subcutaneous route of administration is not recommended because of its delayed and unpredictable responses.

Show References

• The National Institute of Health Stroke Scale (NIHSS) is a well-validated, highly reproducible tool that is widely used to measure neurologic deficit and as a scoring system for stroke intervention.
• This scale is heavily weighted toward recognizing deficit due to anterior circulation strokes, however, while that due to posterior circulation strokes receives fewer points.
• One study found that nearly 1% of patients with MRI-confirmed acute ischemic stroke patients scored zero points on the NIHSS, and that the majority of these were posterior strokes.  These types were more likely to present with truncal ataxia (most commonly), headache, vertigo, and nausea.
• Take home points:  (1) The NIHSS should not replace a thorough neurological examination.  (2) Consider posterior stroke as the source of persistent symptoms in patients with an NIHSS score of zero. 

Show References

Posterior reversible encephalopathy syndrome (PRES) is a syndrome of visual loss, headache, altered mental status, and seizures, typically with severe hypertension. PRES usually occurs with hypertensive encephalopathy or ecclampsia, although cyclosporin and tacrolimus use have been implicated. 

PRES is due to a combination of endothelial damage, impaired auto-regulation and increased cerebral perfusion pressure. Classic CT and MRI findings are parietal-occipital, cerebellar, or brainstem cortical and subcortical edema. 

Early recognition and symptomatic treatment is key; IV anti-hypertensives (hypertensive encephalopathy), anti-epileptics (seizures), IV magnesium and emergent delivery (ecclampsia), and discontinuing offending medications (cyclosporin and tacrolimus).  

With treatment, partial to complete recovery is normal, although residual neurological and visual deficits may persist.

Show References

60 year-old male s/p assault. + LOC. Awake and normal neuro examination on arrival. Deteriorates in the ED after about an hour....

Diagnosis: Epidural Hematoma

Show References