UMEM Educational Pearls

Category: Pediatrics

Title: Pediatric Status Epilepticus

Posted: 8/26/2009 by Rose Chasm, MD (Emailed: 8/27/2009) (Updated: 3/29/2024)
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  • Status epilepticus is defined as either a continuous convulsion or serial convulsions without loss of consciousness that lasts 30 minutes.
  • First line treatment:  benzodiazepine because it is absorbed rapidly into the nervous system; lorazepam (0.05 to 0.1 mg/kg) is preferred over diazepam (0.2 to 0.5 mg/kg) because of its longer half-life in the CNS; rectal administration of the intravenous formulation or the commercially available gel at the same doses may be subsitutued if no IV is attainable.
  • if seizure activity persists beyond 10 - 15 min, a longer acting anticonvulsant such as phenytoin (18 -20 mg/kg), fosphenytoin, or phenobarbital (18 - 20 mg/kg) is administered; they take longer to penetrate the CNS, but have much longer half-lives than the benzodiazepines.  Phenobarbital is given to infants while phenytoin or fosphenytoin is given to older children.
  • Fosphenytoin, a prodrug to phenytoin, increasingly is replacing phenytoin as the drug of choice.  It can be administered at two to three times the rate of phenytoin and is less caustic to skin in teh event of vein extravasation.  It can als be given intramuscularly, while phenytoin can't.

 

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Category: Neurology

Title: First-time Seizures: Labs to Check

Keywords: seizure, first-time seizure, new onset seizure (PubMed Search)

Posted: 8/26/2009 by Aisha Liferidge, MD (Updated: 3/29/2024)
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  • Glucose abnormalities and hyponatremia are the two laboratory findings most frequently associated with triggering first-time seizures in adult patients.
  • Always check an HCG in women who present with their first seizure, as this may reveal the source (i.e. eclampsia) and/or may affect testing, disposition, and initiation of an anti-epileptic drug (AED).
  • Drug abuse screens should be considered in patients with their first seizure, but no prospective studies have demonstrated benefit from routine use.

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Category: Critical Care

Title: PPV and Volume Assessment

Posted: 8/25/2009 by Mike Winters, MD (Updated: 3/29/2024)
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Pulse Pressure Variation and Volume Responsiveness

  • Assessing volume status in the critically ill is extremely challenging, as up to 50% of patients do not respond to a fluid challenge (i.e. increase their stroke volume/cardiac output with additional IVFs).
  • As highlighted in previous pearls, traditional measurements such as blood pressure, heart rate, and urine output are extremely variable and inaccurate in determining volume status.
  • Pulse pressure variation is an emerging method of volume assessment that, to date, seems even better than ultrasound measurements of the IVC.
  • To calculate PPV, print out a tracing from an arterial line that captures both inspiration and expiration use the following formula:
    • ΔPP = 100 × (PPmax - PPmin)/[(PPmax + PPmin)/2]
  • Values > 13% indicate that the patient is likely on the ascending portion of their Starling Curve and will augment their cardiac output with additional IVFs.
  • Note that arrhythmias and spontaneous breathing can affect measurements, thus patients should be mechanically ventilated and well sedated when measuring PPV.

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Category: Vascular

Title: Unusual Presentations of AAA

Keywords: AAA (PubMed Search)

Posted: 8/24/2009 by Rob Rogers, MD (Updated: 3/29/2024)
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Unusual Presentations of AAA

Many unusual presentations of AAA have been reported in the literature and include:

  • Musculoskeletal complaints (thigh or groin pain)
  • Bilateral testicular pain
  • Unexplained inguinal pain-VERY well described
  • Femoral neuropathy
  • Abdominal pain and urge to deficate (and, NO, I am not making that one up)

One more note on the whole urge to deficate thing: any thing that leads to hemoperitoneum may cause this strange complaint (ruptured AAA, ruptured ectopic pregnancy).

 



Category: Geriatrics

Title: temperature in the elderly

Keywords: hyperthermia, heat stroke (PubMed Search)

Posted: 8/23/2009 by Amal Mattu, MD (Updated: 3/29/2024)
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Be wary of the limitations of correlating a temperature with infection in the elderly:
1. The elderly are 3-4x more likely to develop hypothermia in response to serious infections. Never rule out a serious infection simply based on a low or normal body temperature.
2. The elderly take longer to mount a fever than younger patients.
3. The elderly have a slightly lower body temperature at baseline, possibly 1 degree lower. As a result, "fever" in the elderly is sometimes defined as 99.5 degrees rather than the traditional 100 or 100.4 used in younger patients.



Category: Pediatrics

Title: Hypertensive Encephalopathy

Keywords: Pediatrics, hypertension, encephalopathy (PubMed Search)

Posted: 8/22/2009 by Reginald Brown, MD
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Hypertensive encephalopathy is generally seen in children with renal disease, e.g. acute glomerulonephritis or ESRD. 

Signs and symptoms include bp >99th percentile for age and height and neurologic impairment.  May present acutely with seizure or coma, or subacute with HA, vomiting, lethargy, blurry vision or change in mental status.  Exam findings may also include papilledema.

MRI may show increased signal in occipital lobes of T2 weighted images, known as reversible posterior leukoencephalopathy.

Treatment is to lower BP by 20-25% for the first 8 hours and to normative levels over 24-48 hrs.  IV therapy with esmolol drip, labetalol or nicardapine are the treatments of choice.  Nitroprusside prudent in most hypertensive adult emergencies must be used cautiously  if history of renal disease secondary to cyanide toxicity. Seizure should also be treated as you would with status epilepticus.

 

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Category: Obstetrics & Gynecology

Title: Rhogam Dosing

Keywords: Rhogam, Pregnancy (PubMed Search)

Posted: 8/22/2009 by Michael Bond, MD (Updated: 3/29/2024)
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Rhogam Dosing:

Though most textbooks recommend Micro-Rhogram (50mcg) for woman that have miscarried and are less than 12 weeks gestation, you might find it a real challenge to get that dose from your pharmacy or blood bank.

The cost difference between microRhogram and Rhogam is minimal so most hospitals have decided to only stock full dose (300 mcg) Rhogam.  The full dose can be given to woman in their 1st trimester without any deleterious effects. 

Just remember if you are giving it as a result of a delivery you should order a Kleihauer-Betke test to determine if additional doses of Rhogam are needed.



Category: Toxicology

Title: Priapism - Drugs that Cause It

Keywords: priapism, yohimine, trazadone (PubMed Search)

Posted: 8/20/2009 by Fermin Barrueto, MD (Updated: 3/29/2024)
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Priapism - prolonged involuntary erection - is an adverse effect with some drugs. Here is a list of the more commonly reported:

  • Androgens
  • Anticoagulants
  • Antihypertensives: Hydralazaine, labetolol, phentolamine, prazosin
  • Antipsychotics
  • Cantharidin
  • Cocaine
  • Diazepam
  • Marijuana
  • Sildenafil
  • Trazadone
  • Yohimbine


Category: Neurology

Title: Altered Level of Consciousness Pearl

Keywords: correction to altered level of consciousness pearl (PubMed Search)

Posted: 8/20/2009 by Aisha Liferidge, MD (Updated: 8/22/2009)
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  • To be conscious, one must be both awake and alert.
  • Patients who sustain severe anoxic cortical damage, with brainstem sparing, exhibit wakefulness and sleep, but are not aware, and thus, are unconscious.
  • This description is the hallmark of a "vegetative state."
  • A coma is a deep depression in the state of altered level of consciousness, which is characterized by the patient's response to verbal or painful stimuli.


High Frequency Oscillatory Ventilation (HFOV)

  • Although traditionally used in neonates, HFOV is becoming increasingly popular for select adult patients with ALI/ARDS.
  • Benefits of HFOV include:
    • use of smaller tidal volumes than conventional ventilation
    • maintains alveoli open at a relatively constant airway pressure thereby preventing atelectrauma
    • improves ventilation/perfusion
  • Indications for use of HFOV are when:
    • conventional ventilator settings require an FiO2 > 70% and PEEP > 14 cm H2O OR
    • pH < 7.25 despite higher tidal volumes and plateau pressures > 30 cm H2O
  • Key variables, along with suggested initial settings, for HFOV include:
    • Frequency: 4 - 7 Hertz
    • Amplitude: 70 - 90 cm H2O
    • Mean airway pressure: 5 cm H2O greater than last plateau pressure measured on conventional setting
    • Bias flow: 40 L/min
    • Inspiratory time: 33%
    • FiO2: 100%

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Beware of older patients with groin pain!

Lower abdominal pain (mimicking diverticulitis) and isolated groin/hip pain are relatively common presentations of AAA and iliac artery aneurysm and rupture. As many as 15-20% of symptomatic AAAs wil present with hip and/or groin pain.

Bottom line: AAA and iliac artery aneurysm should at the very least be considered in older patients (and in patients with vascular disease) who present with unexplained groin/hip pain.



Category: Cardiology

Title: acute aortic regurgitation

Keywords: aortic, regurgitation, valvular disorders (PubMed Search)

Posted: 8/15/2009 by Amal Mattu, MD (Updated: 3/29/2024)
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Acute aortic regurgitation pearls:
1. Most common cause is infective endocarditis
2. Also consider thoracic aortic dissection (chest pain plus new diastolic murmur)
3. Is the most common post-traumatic valvulopathy (chest trauma plus new diastolic murmur)
4. Presentation: diastolic decrescendo murmur at upper sternal border, may radiate to neck, hypotension, pulmonary edema
5. Treatment: get them to the OR! in the meantime, use vasopressors to support BP and afterload reduction to improve the pulmonary edema



Category: Endocrine

Title: Apathetic Hypothyroidism

Keywords: Hypothyroidism, Elderly (PubMed Search)

Posted: 8/15/2009 by Michael Bond, MD (Updated: 9/5/2009)
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Apathetic Hypothyroidism AKA Hypothyroidism in the Elderly

Remember that elderly do not present with classic signs and symptoms of hypothyroidism, but rather it is more common for them to have atypical presentations.

Things that make the diagnosis more difficult in the elderly are:

  • The thyroid gland is often difficult to palpate.
  • Symptoms like weight gain, cold intolerance, and mental and physical decline are often attributed to the normal aging process.
  • Symptoms are often attributed to medications, or medications mask some of their symptoms.


Consider the diagnosis in elderly patients with:

  • Arrthymias
  • New onset dementia or increased “forgetfulness”
  • Depression
  • Failure to thrive
  • Anemia
  • Hyponatremia

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Category: Pediatrics

Title: Sickle Cell and ACS

Keywords: ACS, Sickle Cell (PubMed Search)

Posted: 8/14/2009 by Adam Friedlander, MD (Updated: 3/29/2024)
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PEARL: Any patient that in your Emergency Department with a sickle cell disease (SCD)-related diagnosis requires incentive spirometry and frequent monitoring for acute chest syndrome (ACS).


BRIEF WHY: ACS is the most common cause of hospitalization and death in patients with SCD.1,2 

Nearly half of all patients who develop ACS are admitted for diagnoses other than ACS.  Of those not admitted with ACS, radiographic and clinical findings of ACS appeared a mean of 2.5 days after admission.2 It is because of this that all patients with SCD related diagnoses at presentation, must be treated as though they are in the prodrome stage of ACS, and all require incentive spirometry to reduce the risk of progression to ACS.2


More to come... 

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Category: Toxicology

Title: Acute Withdrawal of Prostacylcin Analogues for Pulmonary Hypertension

Keywords: treprostinil, epoprostenol, pulmonary hypertension (PubMed Search)

Posted: 8/12/2009 by Bryan Hayes, PharmD (Emailed: 8/13/2009) (Updated: 3/29/2024)
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One of the treatment options for NYHA class III and IV pulmonary hypertension is prostanoids.  All of the prostanoid formulations have the limitations of a short half-life and a heterogeneous response to therapy.  Because the drugs need to be given by continuous infusion, patients may present to the ED due to pump failure.  Sudden cardiopulmonary collapse can occur with infusion interruption.  Here are some important points to remember regarding kinetics:

  • Intravenous epoprostenol (Flolan®) has an extremely short half-life (2–3 min) and lacks stability at room temperature.  Interruption of the pump for even a short period can have drastic consequences.
  • Treprostinil (Remodulin®) has theoretical advantages over epoprostenol because of its stability at room temperature, an elimination half-life of 4-6 hours (subcutaneous), and its ability to be administered by continuous subcutaneous infusion.


Category: Neurology

Title: Signs and Symptoms of Dysarthria

Keywords: dysarthria, stroke (PubMed Search)

Posted: 8/12/2009 by Aisha Liferidge, MD (Updated: 3/29/2024)
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Depending on the location of infarct, stroke patients with dysarthria (a motor speech disorder) may exhibit the following signs and symptoms:

  • "Slurred" speech
  • Speaking softly or barely able to whisper
  • Slow rate of speech
  • Rapid rate of speech with a "mumbling" quality
  • Limited tongue, lip, and jaw movement
  • Abnormal intonation (rhythm) when speaking
  • Changes in vocal quality ("nasal" speech or sounding "stuffy")
  • Hoarseness
  • Breathiness
  • Drooling or poor control of saliva
  • Chewing and swallowing difficulty


Category: Critical Care

Title: APRV

Posted: 8/11/2009 by Mike Winters, MD (Updated: 3/29/2024)
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Airway Pressure Release Ventilation (APRV)

  • As emergency physicians manage mechanically ventilated patients for longer periods of time, it is important to be familiar with newer, alternative modes of ventilation
  • APRV is an open-lung ventilation strategy designed to provide oxygenation benefits while augmenting ventilation for patients with low compliance lung disease
  • APRV has been described as CPAP with brief, regular, intermittent releases in airway pressure - essentially cycling between two CPAP levels
  • The degree of ventilatory support is determined by the duration at each of the 2 CPAP levels and the distending pressure
  • The 5 major parameters of APRV, along with suggested initial settings include:
    • Phigh (high pressure): set at desired plateau pressure
    • Thigh (time spent at the high pressure): 4-6 seconds
    • Plow (low pressure): 0 cm H2O
    • Tlow (time spent at the low pressure): 0.6-0.8 seconds
    • FiO2: 100%
  • The pressure gradient between Phigh and Plow, Tlow, and the patient's spontaneous minute ventilation are the primary determinants of alveolar ventilation
  • When using APRV, be sure to optimize intravascular volume to offset the decrease in venous return that results from prolonged positive intrathoracic pressure

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Category: Pediatrics

Title: Pertussis

Keywords: Pertussis, Whooping Cough (PubMed Search)

Posted: 8/9/2009 by Heidi-Marie Kellock, MD
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Pertussis (Whooping Cough):

  • Caused by B.pertussis and B.parapertussis
  • Incubation period = 6 days
  • Three stages:  Catarrhal (low-grade fever, rhinorrhea);  Paroxysmal (classic "whooping" cough);  Convalescent (resolution of symptoms over a ~2wk period)
  • Full course of the disease = on average 6-8 weeks, although convalescent stage may last MONTHS
  • Erythromycin may be effective early on, but no effect once in the paroxysmal stage
  • Complications are most common in neonates and infants, and notably, the elderly
  • Complications include apnea, hypoxia, pneumonia, encephalopathy, pneumothorax/pneumomediastinum (from paroxysms in the setting of severe mucus plugging)

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Category: Endocrine

Title: Cushing Syndrome

Keywords: Cushing Syndrome (PubMed Search)

Posted: 8/9/2009 by Michael Bond, MD (Updated: 9/5/2009)
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Cushing Syndrome

The most common cause of Cushing syndrome is the use of exogenous glucocorticoids, and it is rarer to have a problem with the hypothalamic-pituitary-adrenal axis.

These patients can present with:

  • proximal muscle weakness
  • easy bruising
  • weight gain
  • hypertension
  • diabetes
  • impaired immune function
  • infertility or menstrual irregularities

For the emergency department we need to be worried about those on chronic steroids that can not increase their native steroid production in a time of stress which will lead them to adrenal crisis.

Pearls for those with Cushing Syndrome:

  • May have perforated viscous with minimal peritoneal signs
  • Suspectable to fungal infections so consider adding fluconazole to those that are septic
  • Give a large dose of hydrocortisone 100mg PO/IV every 8 hours if you suspect adrenal crisis.


Category: Toxicology

Title: Vicks VapoRub Toxicity

Keywords: Menthol, camphor, vicks, seizure (PubMed Search)

Posted: 8/6/2009 by Ellen Lemkin, MD, PharmD (Updated: 3/29/2024)
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Vicks VapoRub Toxicity

With the removal of OTC product indications for children under the age of 2 for cough and colds, more parents are turning to other agents such as Vicks VapoRub for the relief of cough and cold symptoms. Unfortunately these agents are also associated with toxicities and the potential exists for an increased number of poisonings. The primary components of these agents are:

  • Camphor
  • Eucalyptus Oil
  • Menthol

Menthol is used to relieve symptoms of chest congestion. There is NO data to support efficacy, and paradoxically, studies have indicated increased airflow resistance with application. There is a case report of an 18 month old who developed respiratory distress after application. Symptoms associated with overdose, or inappropriate route (mucosal, oral) are:

  • Aspiration
  • Apnea
  • Laryngoconstriction
  • Nausea
  • Ataxia
  • Cardiac and CNS toxicity (confusion, euphoria)

Camphor in products with higher concentrations such as Campho-phenique can cause additional toxicity with effects:

  • GI symptoms
  • CNS: confusion, hallucinations, excitation, coma, seizures
  • Apnea
  • Asystole

Treatment for both is supportive.
 

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