UMEM Educational Pearls

• While seizure is rarely associated with stroke during its hyperacute phase, Arboix found that the development of epileptic strokes within the first 48 hours post-stroke occurs about 2.4% of the time and portends a higher degree of in-patient mortality.
• Seizure activity in the setting of acute stroke is more commonly associated with hemorrhagic types (4.3 % of cases), compared to just 2% with ischemic strokes.
• Younger age, acute confusional states, hemorrhagic strokes, cortical strokes, and strokes affecting the frontal, parietal, occipital, and temporal lobes were found to be risk factors for stroke-related seizures.
• The use of prophylactic anti-epileptic medication in the acute phase of stroke varies and, some say, requires further research; such treatment is more commonly reserved for use in hemorrhagic stroke patients, however, if at all.

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The term Sepsis is frequently and colloquially used to describe "sick" patients; but accuracy requires understanding the specific criteria of Sepsis and its associated syndromes.  Following are the defining criteria for SIRS and Sepsis:

SIRS

at least 2 of the following:

Temp >38C or <36C

Heart rate >90

RR> 20 or pCO2<32mm Hg

WBC>12,000, <4,000 or >10% bands

Sepsis:

Systemic response to infection, manifested by 2 or more SIRS criteria with a source of infection confirmed by culture or a clinical syndrome pathognomic for infection.

Severe Sepsis:

Sepsis associated with acute organ dysfunction, hypoperfusion or hypotension; including lactic acidosis, oliguria or altered mental status.

Septic Shock:

Sepsis-induced hypotension not responsive to fluid resuscitation.

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Altered Mental Status-Three Diagnoses That Can "Bite You On The Buttocks"

When evaluating the patient who is altered, consider the following diagnoses:

1. DTs-seems simple enough, right? Remember that some altered patients will not be able to give a history of alcoholism. And this is definitely a diagnosis that can sneak up on you. Bottom line: consider DTs in ALL patients with a delirium.

2. Wernicke's encephalopathy-can also be very difficult to detect. Consider in ALL alcoholic patients with altered mental status and give Thiamine. 

3. Herpes encephalitis-speaking from personal experience, this diagnosis can be extremely tough to diagnose. Consider giving emperic Acyclovir in patients with WBCs in their CSF and a negative gram stain. And don't forget to send off a Herpes PCR. As far as clinical presentations, CNS Herpes can present with a wide spectrum of findings, from isolated headache, to new psychobehavioral changes, to severe depression of consciousness and coma. Be aware that this diagnosis isn't common but failure to initiate Acyclovir may be a fatal mistake. 

Though most people know that therapeutic hypothermia is indicated in resuscitated victims of cardiac arrest, is it safe if that cardiac arrest victim is also being treated for STEMI? Do you need to worry about increased bleeding complications in these patients that are receiving anticoagulants, lytics, PCI, or other standard "bleeding" medications? Are these patients at increased risk for hemodynamic instability with therapeutic hypothermia?

Recent studies have demonstrated that therapeutic hypothermia in acute MI patients receiving other standard treatments (i.e., anticoagulants, etc.) is SAFE: it is associated with no increase in bleeding complications (1), no increase in time to balloon inflation (2), and no increase in hemodynamic instability or malignant arrhythmias (3).

1. Schefold JC, et al. Mild therapeutic hypothermia after cardiac arrest and the risk of bleeding in patients with acute myocardial infarction. Int J Cardiol 2009;132:387-391.
2. Knafelj R, Radsel P, Ploj T, et al. Primary percutaneous coronary intervention and mild induced hypothermia in comatose survivors of ventricular fibrillation with ST-elevation acute myocardial infarction. Resuscitaiton 2007;74:227-234.
3. Wolfrum S, Pierau C, Radke PW, et al. Mild therapeutic hypothermia in patients after out-of-hospital cardiac arrest due to acute ST-segment elevation myocardial infarction undergoing immediate percutaneous coronary intervention. Crit Care Med 2008;36:1780-1786.

Acute paronychia

• Usually result from minor trauma of the skin around the fingernail such as biting, manicures, picking a hangnail or finger sucking.
• Staphylococcus aureus is the most common infecting organism. However other mouth flora such as Streptococcus and Pseudomonas species, gram-negative bacteria, and anaerobic bacteria can also be a cause.
• Recommended treatement consists of incision and drainage and placing the patient on  amoxicillin /  clavulanic acid or clindamycin to cover all the organisms noted above.

Hyperleukocytosis is often seen in acute presentations childhood leukemias, and is defined as a WBC count of greater than 30-50K.  Complications usually arise at counts greater than 300, however, keep in mind that automated cell counters may underestimate very high white counts.

Complications include:

• Hyperviscosity Syndrome / Leukostasis
  • Risk of CVA, PE, Mesenteric Ischemia, etc.
• Tumor Lysis Syndrome (TLS)
  • Risk of fatal arrhythmia, may monitor with K, LDH, Uric Acid
• Disseminated Intravascular Coagultion (DIC)

Treatment:

• EMERGENT LEUKOREDUCTION APHERESIS, aka Leukopheresis
• This is a true emergency - if you are at a facility without leukopheresis capability, the fastest transport mode possible is indicated - fly, don't drive
• Temporizing measures include fluids, fluids, and fluids
• Allopurinol / Rasburicase may be considered, but not if this will delay transport, especially if there is no evidence of TLS - this decision may be made in consultation with the pediatric heme/onc specialist who is helping to arrange for leukopheresis

SUCCIMER (DMSA)

• An oral agent used for the chelation of heavy metals, such as LEAD, ARSENIC and MERCURY
• Forms a water soluble agent that chelates the heavy metal, which are renally excreted
• Most common side effects are rashes, urticaria and GI
• A serious adverse effect is neutropenia, which is rare

Cortical versus Subcortical Strokes

• Gray matter (neuronal cell bodies) of the brain forms a rim over the cerebral hemispheres, forming the cerebral cortex.
• White matter (neuronal axons coated in myelin) is located below the cortex and makes up the "subcortical" regions of the brain.
• Strokes affecting the cerebral cortex (i.e. cortical strokes) classically present with deficits such as neglect, aphasia, and hemianopia.
• Subcortical strokes affect the small vessels deep in the brain, and typically present with purely motor hemiparesis affecting the face, arm, and leg.
• Nearly 30% of all ischemic strokes are subcortical in nature, and includes lacunar infarcts which have the best prognosis.

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Aisha T. Liferidge, MD, FACEP
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Assistant Professor, Attending Physician
University of Maryland School of Medicine
Department of Emergency Medicine
Baltimore, MD 21201
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MPH Candidate, Columbia University 2011

AKI and the Critically Ill

• Acute kidney injury (AKI) is an abrupt reduction in kidney function causing disturbances in electrolytes, fluids, and acid-base balance.
• AKI occurs in up to 67% of critically ill patients and is associated with a substantial increase in morbidity and mortality.
• AKI in the critically ill is often multifactorial and most commonly due to sepsis, hypovolemia, medications, and hemodynamic instability.
• Medications account for up to 20% of AKI in the critically ill.
• Common medications that cause, or exacerbate AKI, in the critically ill include:
  • NSAIDS
  • Antibiotics (aminoglycosides, amphotericin, acyclovir)
  • ACE-inhibitors
  • Radiocontrast dye
• Take Home Point:  AKI is common in our critically ill ED patients and, whenever possible, avoid nephrotoxic medications that can result in additional injury.

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  Despite the traditional use of intravenous medications such as vasopressors and antiarrhythmics for victims of cardiac arrest, there is actually very little evidence to support these therapies. On the contrary, 2 recent multicenter center studies demonstrated that the use of intravenous medications that are advocated in standard advanced cardiac life support (ACLS) guidelines are ineffective at improving survival to hospital discharge of patients with primary cardiac arrest. In contrast, these medications have been shown to increase hospital admissions, bed and resource utilization, and costs. The only interventions that have been shown to improve meaningful outcomes are rapid defibrillation for shockable rhythms, good compressions, post-resuscitation therapeutic hypothermia, and there's increasing evidence for post-resuscitation cardiac catheterization as well.

In other words, the best thing you can do early for patients with primary cardiac arrrest is to focus on the basics.

 

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Pityriasis Rosea

• A common exantham that typically presents initially with a herald patch, followed by a generalized rash over the next 1-2 weeks and can last 4-6 weeks.
• Patients may initially have prodromal symptoms such as joint pain,headache, fever and malaise that precede the appearance of the rash.
• The primary plaque, herald patch, is seen on the skin in 50-90% of cases.
• The generalized rash typically develops in crops along the lines in the skin leading to a characteristic "Christmas tree" pattern.
• Pruritus is present in 75% of cases.
• Usually a self-limited, benign illness that does not require any treatment.  Though symptomatic treatment of the pruritus is reasonable.

Meningitis Prophylaxis in Children

While H1N1 and garden-variety influenza have been taking the spotlight lately, we can't forget about other disease processes.  Meningitis is still a severe, life-threatening/altering process which occurs in various social groups (e.g. military cadets, college students).

However, with more of our parents working out of the home, child care is more often the norm, and as such, you may find yourself dealing with cases of children who have been in proximity to another child or caregiver diagnosed with meningitis.  What do you do?

The causative agent will often dictate your choice of management.

Neisseria meningitidis - nursery/child care contacts should receive chemoprophylaxis and the Menactra vaccine (if they have not already received it) within 7 days of onset;  casual school or work contacts do NOT require prophylaxis

Streptococcus pneumoniae - no chemoprophylaxis or vaccination required (unless series was not continued)

Haemophilus influenzae - if only one case reported, no intervention;  if 2 or more cases within a 60-day period, Hib vaccination and chemoprophylaxis with rifampin for BOTH children and caregivers (especially if the center cares for young children who have not completed their Hib series)

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• Non-enhanced Brain CT (NECT) offers low yield in terms of its diagnostic utility for acute ischemic stroke (AIS), with sensitivities less than 67% at 3 hours out from symptom onset.

• A hyperdense middle cerebral artery (MCA) sign may represent acute thrombus and predicts impending large territorial infarct of poor prognosis (*see images of MCA Sign (left) and subsequent territorial edema representing infarct (right) below).

• While MCA Signs occur somewhat rarely, this finding is one of the earliest and most useful indicators of probable (clinical) stroke on NECT, and should be a recognizable hallmark for the emergency physician.

• Note that hyperdense MCA's can mimic a thrombus and actually represent atherosclerotic calcifications.

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How to stop dialysis fistula/graft bleeding

The number of patients being placed on hemodialysis seems to be increasing. And the ED is where they will go when there is a any complication from their fistula or graft.

Hemodialysis shunts require cannulation with large bore instruments. This combined with heparinization may lead to prolonged bleeding from puncture sites. 

What to do when a patient shows up in the ED with persistent bleeding from a fistula puncture site:

• Simple pressure may be all that is required in many cases. 
• If this doesn't work, place a single circular suture around the puncture site/incision. In some small studies this has been shown to be very useful in stopping persistent oozing

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Nikolsky's sign is positive when slight rubbing of the skin results in exfoliation of the skin's outermost layer.  The more technical term is acantholysis which is the loss of the normal adhesion of the epithelial skin cells which allows for this sloughing.

Seen in:

• Toxic Epidermal Necrolysis
• Pemphigus vulgaris
• Scalled Skin Syndrome
• Bullous impetigo
• Epidermolysis bullosa

Often helpful to differentiate pemphigus vulgaris from bullous pemphigoid. The sign is usually absent in bullous pemphigoid.  Just be careful with how much testing you are doing as this can be very painful to the patient.
 

After seeing all the electrical and extension cords supplying various seasonal holiday decorations, I thought this would be appropriate.

• most commonly occurs once children establish a grasp at 4months and 4 years when children finally learn not to touch cords, but most common from 1-2 years
• not surprisingly, more common in boys (60%)
• moist oral cavity creates a short circuit and electric arc which produces enough heat (up to 1371C/2500F) to cause a low-voltage electric burn
• 5% may suffer cardiac/respiratory arest
• electrical mouth burns result in significant soft tissue damage which forms an eschar
• beware sloughing of the nonviable eschar from the underlying viable tissue around week 2, that results in labial artery hemmorhage

A quick christmas one:

The Christmas Rose (Helleborus niger)

Actually containes cardioactive steroids - eating it will help your A fib with RVR as it will act like digoxin, as well as kill like it.

Attachments

0912242222_christmasrose.jpg (30 Kb)

• Elevated intracranial pressure (ICP) can sometimes be associated with focal symptoms related to mass lesions or herniation syndromes.

• Herniation is the result of pressure gradients between two regions of the cranial vault, such as that related to cerebral edema from an acute stroke.

• The following list describes areas most commonly affected by herniation syndromes: 

          --- subfalcine

          --- central transtentorial

          --- uncal transtentorial

          --- upward cerebellar

          --- cerebellar tonsillar/foramen magnum

          --- transcalvarial

Appropriate Antimicrobial Therapy for Sepsis

• In previous pearls, we have discussed the importance of early antimicrobial administration for patients with sepsis.
• In patients with septic shock, current guidelines recommend empiric antimicrobial therapy be initiated within 1 hour.
• Equally as important as early administration is the selection of appropriate antimicrobial therapy (i.e. choosing an antibiotic that is effective against the presumed or identified pathogen).
• In one of the most recent studies, investigators found a 5-fold reduction in survival (52% vs. 10.3%) between patients who received appropriate antibiotics compared to those who received antibiotics that were ineffective against the identified pathogen.
• In fact, choosing the right antibiotic is one of the strongest factors associated with patient outcome in sepsis.
• When selecting empiric antimicrobial therapy for patients with septic shock consider patient history, co-morbidities, the clinical site of infection, and local resistance data.

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