UMEM Educational Pearls

Diarrhea and the Petting Zoo

Now that it is Spring Time, trips to the Zoo and to Pools will become more frequent… consider them as potential environmental exposure sites.

Petting Zoos, Farmers Markets and Fairs, and Swimming Pools (especially kiddie swimming pools) are known sources of enteropathogens that can cause diarrhea (sometimes bloody).

• Salmonella (turtles, baby chicks)
• E. Coli (newborn calves)
• Cryptosporidium (farm animals and swimming pools – it is chlorine resistant)

Consider these on your DDx of vomiting/diarrhea.

Ask about these possible exposure sites along with Travel History and Nontraditional Pets.

Heparin FDA Alert

In case you had not heard, there was a major recall of Baxter's Heparin. It was responsible for dozens of deaths in the USA and an investigation was launched. It has been found that the contaminant comes from manufacturing plants in China. The most concerning part is that it looks like it was chemically synthesized sulfated chondroitin. This brings the suspicion of intentional adulteration. First lead in toys now cartilage in our heparin - what's next?

Some fascinomas of Heparin:

• Overdose of heparin is treated with either time or protamine
• Protamine can actually worsen anticoagulation if you give too much
• Dose of Protamine: 1 mg of Protamine neutralizes 90 USP Units of Heparin but you must cut dose in half if 30 minutes have passed from heparin dose

News link for FDA Heparin Alert:

http://www.fda.gov/medwAtch/safety/2008/safety08.htm#HeparinInj2

• The risk of symptomatic intracerebral hemorrhage after use of IV tPA for acute stroke is 6% (within 36 hours of administration).

The NINDS tPA Stroke Study Group.  "Intracerebral Hemorrhage after Administration of Intravenous tPA for Ischemic Stroke."  Stroke.  1997; 28:  2109-18.

Potassium Phosphate ("K-phos")

Over the weekend, I had a patient with Dr. Scott that had a phosphate of 0.8 mmol/L.  Phosphate < 1.0 mmol/L is an indication for IV repletion.  IV repletion involves giving potassium phosphate.  An important clinical question, therefore, is how much potassium does the patient actually get?

• 1 mmol of IV phosphate delivers 1.46 mEq of potassium
• Recommended infusion rate is 5 mmol/hr
• Rapid infusion may lead to severe hypocalcemia, hypotension, acute renal failure, hypomagnesemia, and hypernatremia

Cardiogenic shock associated with LV outflow obstruction is managed best without the use of vasoconstrictive agents and vasopressors. Ideally, patients should be treated with IVF and beta blockade. Alpha agonists (e.g. ISO) can also be added.

Typical vasopressors may actually worsen LV outflow obstruction in these patients.

Dental Emergency -- Avulsed Tooth

• Never reimpant a primary tooth.  If replaced, primary teeth have a high likelihood of fusing to underlying alveolar bone, which causes dentoalveolar ankylosis and can result in facial deformities
• Never wipe off a tooth, or hold it by the root. The periodontal ligament is easily wiped off and the tooth will not reimplant without it.
• For maximal success, the tooth should be reimplanted within 60 minutes.
• Avoid allowing the periodontal ligament from drying out.  Transport the tooth in (listed in order of preference):
  • Hanks Solution or EMT Tooth Saver
  • Milk
  • Saline
  • Saliva
• Once the tooth is reimplanted it should be held in place with a wire splint or Coe-Pak that bridges the avulsed tooth to the ones on either side of it.
• Place the patient on antibiotics (Penicillin or Clindamycin) in order to prevent any infections.
• If the avulsed tooth can not be found a Chest X-ray should be obtained to ensure that the tooth was not aspirated.

Sexual Abuse

• The only positive vaginal culture that is DEFINITIVE confirmation of sexual abuse is Neisseria gonorrhea.
  • Vertically transmitted Chlamydia may persist for up to 3 years (does not confirm abuse in children <3yrs)
  • Syphilis may also be present due to vertical transmission (often presents as secondary syphilis)
  • Trichomonas can also be transmitted perinatally and may persist for 6-9 months. 
    • However, it has NOT been found in children >1 year without history of sexual contact.

• Remember that CULTURES need to be sent for GC and Chlamydia.  DNA probes and nonculture methods are NOT recommended in this age group for evaluation of potential sexual abuse.
   

• A triptan that is a serotonin agonist
• SQ administration better
• High first pass effect and thus not effective often PO
• Sulfhemoglobinemia see with high dose PO
• Adverse Effects: MI and ischemia , CVA
• Be wary with elderly, hx of CAD/CVA or hx of cocaine use

• The Dix-Hallpike Maneuver is performed to help diagnose/rule out benign positional vertigo, a condition attributed to floating (canalithiasis) or fixed (cupulolithiasis) otoconial debris within the posterior semicircular canal of the ear.
• To perform, turn the patient's head 45 degrees to one side and then rapidly but carefully recline them backwards to a supine position, preferably with the head hanging partially off the bed (i.e. at a position about 10-20 degrees inferior to that of the rest of the body).  Next, perform the maneuver by turning the patient's head 45 degrees to the other side.
• If nystagmus is induced, the test is positive.  Note the following five characteristics of the nystagmus:  (1)  latency, (2)  direction, (3)  fatigue (i.e. extinguishes with repetitive maneuvers), (4)  habituation (i.e. duration), and (5)  reversal upon sitting upright.
• Note that the Dix-Hallpike Maneuver described here is the diagnostic version, not the one performed therapeutically, the latter of which is also helpful. 

 Medical Regimen for Suspected Variceal Bleed

To review what Dr. Bond and Dr. Winters have already posted:

Three medical therapies have been shown to be effective in patients with severe upper GI bleed thought to be due to esophageal varices:

• Octreatide: 50-100 ug bolus followed by 50 ug/hour. Has been shown to lower the rebleeding rate substantially. Even if varices have not been confirmed by endoscopy, Octreatide has also been shown to be effective in ulcer bleeding as well.
• Antibiotics (3rd generation Cephalosporin): Have been to lower the rebleeding rate in variceal bleeding. 
• Intravenous Proton Pump Inhibitor: Remember that a liver patient is as likely to have a non-variceal source of bleeding (ulcer), so add a PPI drip. Raising the pH stabilizes clot. Without endoscopy, you don't know if they have an ulcer or another etiology.

Most of our gastroenterologists recommend this regimen (all three therapies)

Other things to consider:

• Platelets, FFP
• Intubate EARLY-most endoscopists will want the airway protected prior to the scope.
• Don't be too aggressive with blood replacement/IVF: The gastroenterologist don't want these patients too resuscitated with blood products. Certainly don't aim for a Hct >30.

Coagulopathy and Trauma

• When resuscitating a trauma patient recall that the "lethal triad" consists of acidosis, hypothermia, and coagulopathy
• Coagulopathy is induced by the combination of direct loss of clotting factors, consumption in clot formation, dilutional due to crystalloid administration, acidosis, and hypothermia
• When giving PRBCs in trauma resuscitation, don't forget to give FFP
• The ratio to remember is 1U of FFP for every 2U PRBCs

Post-MI cardiogenic shock, while traditionally thought to carry a mortality > 80%, actually has perhaps half that mortality when patients are treated aggressively with prompt invasive therapy (PCI, possibly CABG). Fibrinolytics have traditionally been discouraged, but authors now indicate that they should be given if all of the following three conditions are present:

1. PCI will take greater than 90 minutes,
2. Less than 3 hours have elapsed since onset of STEMI
3. No contraindications to lytics are present.

Sent on behalf of Dr. Amal Mattu

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 Trigeminal Neuralgia

• A neuropathic disorder of the trigeminal nerve that causes episodes of intense pain.
• Also known as Tic Douloureux
• Many cases are associated with vascular compression and subsequent demyelination of the trigeminal nerve, though other causes include compression by a tumor, and multiple sclerosis.
• Classic Trigeminal Neuralgia is a clinical diagnosis that has the following criteria:
  • Paroxysmal attacks of pain lasting from a fraction of a second to two minutes that affect one or more divisions of the trigeminal nerve
  • Pain has at least one of the following characteristics: intense, sharp, superficial, or stabbing precipitated from trigger areas or by trigger factors
  • Attacks are similar in individual patients
  • No neurological deficit is clinically evident
  • Not attributed to another disorder
• Treatment options include:
  • Medical:
    • Carbamazepine (most common and drug of choice)
    • Gabapentin (lacks evidence in trigeminal neuralgia but widely used for other neuropathic pain)
    • Lamotrigine
    • Baclofen
  • Surgical:
    • Microvascular decompression: posterior fossa is explored and the culprit blood vessel is moved off the trigeminal nerve. Typically the nerve is padded with a teflon sheet in order to provide additional protection. 80-90% successful with little or no facial numbness.
    • Ablative: Attempts are made to just incapacitate the pain fibers but these techniques can result in facial numbness as other sensory fibers can be damaged.  Common methods include:
      • Glycerol or alcohol injection
      • Radiofrequency rhizotomies
      • Stereotactic radiation therapy
      • Complete severing of the nerve.

Show References

Acute Appendicitis – Delayed Surgery option?

• Appendicitis incidence in children = 4/1000
• The traditional emergent surgical intervention has recently been challenged.
• Three RETROSPECTIVE studies investigated delayed/urgent vs emergent surgical interventions
  • 2 of the three found no significant difference in perforation or complication rates between the 2 groups.
  • 1 found that the emergent group had higher rates of perforation.
• What you need to know:
  • surgeons may base their decisions on these studies, which do have limitations (being that their retrospective)
  • despite the time of day, you should still advocate for patients that are “sick” to go to the OR rather than get antibiotics to “cool off” first.

Show References

 Did you know how many toxicities and adverse effects amiodarone has? Many are severe, and many VERY common.

1. CARDIAC: hypotension with rapid infusion, prolonged QT, torsades

2. NEUROLOGIC problems occur in 20-40%, including malaise, ataxia, and peripheral neuropathies

3. ENDOCRINE: hypothyroidism and hyperthyroidism

4. GI problems occur in 25%

5. OPHTHALMOLOGIC disturbances include optic neuropathy, papilledema, and photosensitivity

6. SKIN: blue grey pigmentation

7. PULMONARY: pulmonary fibrosis

• Nystagmus which results from gaze (i.e. extraocular motion) in a particular direction, is detected by asking the patient to look at a target object 20 to 30 degrees to the right or left of their midline (i.e. when looking straight ahead) for 20 seconds.
• If gaze nystagmus is present, the eye will beat towards the intended direction of gaze.
• The ability to maintain eccentric gaze is a function of the brainstem and midline cerebellum, particularly the vestibulocerebellum. 
• Gaze nystagmus is attributable to a central process, typically due to drugs (i.e. sedatives, anti-epileptics), alcohol, CNS tumors, or cerebellar degenerative syndromes.

Aspiration Pneumonitis

• Aspiration pneumonitis is an acute lung injury resulting from the aspiration of gastric contents
• It is an inflammatory condition rather than infectious
• Despite the inflammation, corticosteroids have been shown to have no effect on mortality
• Aspiration pneumonitis is self limited
• Antibiotics are generally held for 24 to 48 hours
• When to consider empiric broad spectrum antibiotics in the ED:  Gastric contents are sterile in most patients.  Patients who may have colonization/contamination of gastric contents are more likely to progress from pneumonitis to pneumonia.  Consider empiric antibiotics for aspiration pneumonitis in the patient with SBO, gastroparesis, those receiving enteral feeds through a G- or J-tube, and those on chronic PPI's/antacids.

Clinical Presentation of SVC Syndrome

SVC syndrome (caused either by tumor or thrombosis of the SVC) classically presents with facial swelling, arm swelling, and dilated chest wall veins. The problem in the real world is that often times the manifestaions are a bit more subtle.

Some SVC syndrome pearls:

• Consider the diagnosis in patients with a generalized complaint of facial swelling or "fullness," particularly if they have an indwelling catheter in place.
• Consider in patients who complain there face is swollen or red (plethoric) in the morning, or who notice this when their arms are raised (Pemberton's sign)
• The diagnosis is usually established by CT.
• Patients with SVC syndrome and the complaint of hoarseness or headache should make you nervous, as these symptoms may indicate laryngeal and cerebral edema.
• The importance of examining the neck and chest in ED patients cannot be overemphasized. Often the one clue that leads to the diagnosis is prominent and asymetric neck, upper chest, or shoulder veins.
• Treatment: For tumor related SVC syndrome-head elevation, possibly steroids, radiation therapy (along with biopsy if no cancer diagnosis established); For thrombotic-related SVC syndrome-anticoagulation, Interventional Radiology consult for lytics/stent

Right ventricular (RV) dysfunction in the setting of acute MI accounts for only 5% of cases of cardiogenic shock but carries nearly the same mortality as LV shock. Shock due to RV dysfunction is usually treated by aggressive volume loading with IVF. However...

In some cases of RV dysfunction, RV end-diastolic pressure can be very high, resulting in shiftng of the invterventricular septum into the LV cavity, which in turn decreases LV filling and cardiac output. Aggressive fluid resuscitation in these patients may actually further worsen RV pressures, leading to further reductions in cardiac output. These patients should instead be treated early with vasopressors.

How do you tell if your patient needs aggressive fluid resuscitation or early vasopressors? Bedside ultrasound can be the answer...if you find marked distension of the RV, go with early vasopressors. If the RV appears normal in size (smaller than LV), go with the IVF.

And of course early revascularization is critical as well.

(adapted from: Reynolds HR, Hochman JS. Cardiogenic shock: current concepts and improving outcomes. Circulation 2008;117:686-697.)

It has become standard that close contacts of individuals being treated for bacterial meningitis be treated prophalacticly with antibiotics to prevent additional cases.  Fluoroquinolones, in particular ciprofloxicin, have been the drug of choice as a single dose provided adequate protection.

Now the CDC is reporting the first cluster of fluoroquinolone-resistant meningococcal disease in North America have been documented along the Minnesota-North Dakota border.  As of now, the CDC still recommends ciprofloxacin for all parts of the country except for a 34-county area in the Minnesota-North Dakota area.  In that area the CDC is recommending rifampin, ceftriaxone or azithromycin be used.

This needs to be followed closely as the resistant organism is extremely likely to spread across the country and it will probably this time next year when nobody can use ciprofloxacin anymore.