UMEM Educational Pearls

This review reminds us that discharging emergency department patients with abnormal vital signs is a risk for the patient and the provider. The more abnormal vital signs that are present, the higher the risk of adverse event and subsequent return to the emergency department. 

“Hypotension at discharge was associated with the highest odds of adverse events after discharge. Tachycardia was also a key predictor of adverse events after discharge and may be easily missed by ED clinicians.”

Always address abnormal vital signs in your medical decision making portion of the chart and be very wary of discharging anyone with tachycardia or other abnormal vital signs.

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Continuing with the electrolyte derangements in children: Hyponatremia 

Hyponatremia is defined as a Sodium of less than 135 mmol/L and does not depend on patient age.  

This is the most common electrolyte abnormality in pediatric patients. Excessive free water is often the culprit and is usually thought of in the neonate or infant whose guardians are mixing formula incorrectly. * Additional causes include inappropriate ADH (Antidiuretic hormone) secretion, or in the case of dehydrated patients appropriate ADH secretion. Sodium wasting is rare.  

Total body water (TBW) is important to consider, and preterm neonates have higher TBW (80%) than full term (70%) and 1 year old infants (~60%) putting them at higher risk of hyponatremia.  

Recognizing the volume status of the patient aids in determining the etiology of the hyponatremia and allows for appropriate treatment. This may require obtaining urine sodium.  

Treatment: 

Hypertonic saline should be used only for patients with severe neurologic complications including seizures or altered mentation. In these patients, a hypertonic saline bolus should be given at 3-5 ml/kg of 3% NaCl over 10-15 minutes.  

In hypovolemic patients without neurologic symptoms, fluid resuscitation is the mainstay with caution to increase sodium levels by no more than 6-8mmol/L/day. For euvolemic or hypervolemic patients, fluid restriction is advised.  

Prevention: 

Importantly, when children receive IV fluids, the choice should be made to select isotonic fluids (0.9% NaCl) rather than hypotonic fluids (0.45% NaCl) to avoid iatrogenic development of hyponatremia.  

*Reminder: 2 ounces (about 60 ml) of water should be placed in the bottle, and then 1 full scoop of formula, unless directed to have higher caloric content by their doctor- in which case the amount of formula in the mixture should be higher

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Mycoplasma genitalium (M.genitalium, or Mgen) is a pathogen that is increasingly associated with cervicitis, pelvic inflammatory disease, preterm labor, spontaneous abortion, and infertility. Although many are asymptomatic, M.genitalium can be found in 10-30% of women with symptoms/exam findings of cervicitis. 

NAAT testing for M.genitalium is FDA-approved for use with urine and urethral, penile meatal, endocervical, and vaginal swab samples.

According to CDC guidelines, women with recurrent or persistent cervicitis should be tested for M.genitalium, and testing should be considered among women with PID.  It is not recommended to test for asymptomatic infections at this time, even in pregnancy.

High rates of macrolide resistance in this pathogen make 1 g of Azithromycin insufficient. The recommended regimen for NAAT-positive M.genitalium infections is:  Doxycycline 100 mg PO BID x 7 days to reduce bacterial load, followed by moxifloxacin 400 mg PO daily x 7 days.

Overall, more studies are needed to truly determine the clinical relevance of this pathogen. 

Consider testing for M.genitalium in patients presenting with recurrent or persistent cervicitis or pelvic inflammatory disease, as this may not respond to typical antibiotic regimens.

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Question

The incidence of opioid-overdose-related deaths has clearly increased in the past decade, with recent estimates of up to 17% of OHCA being opioid-related in 2023. [1,2] The use of naloxone for opiate reversal in overdose is well-established, with reasonable inference but no formal proof that its use could help in opioid-associated out of hospital cardiac arrest (OA-OHCA). [3] The August publication of two trials [4,5] retrospectively examining naloxone administration in OHCA offers some perspectives…

• Patients receiving naloxone for OHCA are:
  • More often be younger, with fewer comorbidities, but more often unwitnessed than their non-naloxoned counterparts
  • More likely to have opioid OD as a presumed etiology

and

• Naloxone administration is associated with:
  • Increased rates/odds of ROSC and survival to hospital discharge, whether OD is suspected or not
  • And “early” naloxone (given prior to EMS IV/IO access) is associated with increased rates of DC with good neuro outcome in PEA compared to receipt after IV/IO access or none at all

[View “Visual Diagnosis” for slightly more detail on the referenced studies.]

Bottom Line: While prospective trials are absolutely needed to offer more definitive evidence regarding the use of empiric naloxone in nontraumatic OHCA, the rising incidence of OA-OHCA in the U.S. and current findings are convincing enough to encourage early naloxone administration, especially in populations with higher incidence of opioid use.

U.S. Mortality due to Opioid Overdose (CDC data)

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In this systemic literature review of orthopedic injuries identified in intimate partner violence (IPV) the authors remind us that finger, hand, and especially isolated ulnar fractures are very commonly associated with IPV.  When we see these injury patterns extra effort is required to determine if IPV is involved.  

* IPV = intimate partner violence, UEF = upper extremity fracture, and UEI = upper extremity injury.

† Summary table demonstrating the location prevalence of UEIs caused by cases of IPV. Fractures were quantified separately from other UEIs in this specific table.

‡ In all included articles the most common injury type was an injury to the head or neck; these are excluded because of the study aim.

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Autism Spectrum Disorder (ASD) can often be a diagnosis that complicates usual ED evaluation and management. One of the frequently asked questions is “what medications work well for patients with autism?” It is often said, although with quite variable evidence in the literature, that benzodiazepines should be avoided in patients with ASD due to the risk of paradoxical reaction. 

This study was a meta-analysis that included 20 different studies that looked at efficacy and adverse effect of various medications and medication combinations for procedural sedation for a variety of painful and nonpainful procedures. Although the heterogeneity of the indications, medications, and other details of study design of the studies included precludes a definitive recommendation as to the best medication or regimen, it does suggest overall reasonable efficacy of midazolam both as a single agent as well as in combination with dexmedetomidine, especially when balanced against adverse effects noted with some of the more efficacious regimens. 

Take Home Point: Medication choice for patients with ASD should be individualized to the patient based on prior experiences, parental or patient input, and prescriber experience given proven efficacy of multiple regimens. Benzodiazepines should be considered within the toolkit.

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This retrospective study of Swiss trauma patients looked at blood gas oxygen levels within 3 hours of arrival to the trauma bay in severely injured patients over age 16. When comparing hypoxic, hyperoxic and normo-oxic patients there was no difference in 28 day mortality. Those with above normal oxygen levels tended toward longer hospital stays. The above normal oxygen cohort also were more likely to be intubated in the field. 

This study fits with others showing around 20% of trauma patients arrive to our trauma bays over oxygenated. More research is needed to see the impact this has on care. Be mindful of over oxygenation especially in intubated trauma patients.

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Traditional Medicare now covers < 50% of Medicare beneficiaries. It reimburses on a fee-for-service basis. For beneficiaries, it includes deductibles and coinsurance requirements that yield average annual out-of-pocket expenses measured in the thousands of dollars.

Medicare Advantage, the new alternative, has grown quickly. Plans typically promise beneficiaries fewer co-pays and more services. It relies on private insurers (think United, Blue Cross, Kaiser Permanente) to coordinate care and rein in costs. Subsidies to Medicare Advantage have helped spur growth, subsidies that mean costs per beneficiary for Medicare Advantage exceed those for traditional Medicare.

Which means Medicare still needs to figure out how to save money and remain viable while the US population over 65 grows.

When listening to a lecture about Medicare or reading a study that uses Medicare data, take a moment to ask “Which Medicare? Fee-for-service? Or Advantage?”

For a take on the future of Medicare, see McWilliams JM, The Future of Medicare and the Role of Traditional Medicare as Competitor, NEJM, August 22/29, 763-769.

To understand why Medicare Advantage plans are popular, see https://www.kff.org/medicare/issue-brief/10-reasons-why-medicare-advantage-enrollment-is-growing-and-why-it-matters/.

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Hepatorenal Syndrome

• Emergency physicians evaluate patients with cirrhosis and ascites daily.
• Patients with cirrhosis are particularly susceptible to acute kidney injury (AKI), which is associated with a significant increase in hospital mortality.
• Hepatorenal syndrome (HRS) is a specific type of renal dysfunction in patients with cirrhosis and ascites.
• The previous classification of HRS (Type 1, Type 2) has now been replaced by HRS-AKI, HRS-AKD, and HRS-CKD.
• The diagnostic criteria for HRS-AKI include:
  • Increase in creatinine 0.3 mg/dL within 48 hrs or 50% from baseline value within the prior 7 days
  • Lack of improvement in creatinine or urine output within 24 hrs of adequate volume resuscitation
  • Absence of an alternative explanation for AKI
• Management of HRS-AKI centers on accurate volume assessment, timely administration of a splanchnic vasoconstrictor (norepinephrine), administration of 20-25% albumin, and avoidance of additional nephrotoxins.

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We see patients with nausea, fatigue, altered mental status, and other vague symptoms all day, every day in the ED. Let's not forget about hypercalcemia in the differential, especially in patients with a known malignancy!  Many tumor types secrete a Parathyroid hormone (PTH)- related protein that mimics PTH and leads to high calcium levels. 

Here are some clinical pearls on hypercalcemia of malignancy:

• Total serum calcium does not correlate accurately with the physiologically active free form of calcium. If you are concerned, obtain an ionized calcium level OR calculate based on albumin: Corrected Calcium = (0.8 * (Normal Albumin - Pt's Albumin)) + Serum Ca
• ECG findings of hypercalcemia can include:
  • Shortened QT interval
  • ST elevation
  • Osborne waves (positive deflection at the end of the QRS)
  • Bradydysrhythmia
• The degree of elevation correlates with the degree of symptoms (ionized calcium):
  • Mild: Total Ca 10.5-11.9 mg/dL (2.5-3 mmol/L) or Ionized Ca 5.6-8 mg/dL (1.4-2 mmol/L)
  • Moderate: Total Ca 12-13.9 mg/dL (3-3.5 mmol/L) or Ionized Ca 8-10 mg/dL (2-2.5 mmol/L)
  • Severe, aka Hypercalcemic crisis: Total Ca 14-16 mg/dL (3.5-4 mmol/L) or Ionized Ca 10-12 mg/dL (2.5-3 mmol/L)
• IV fluids are the mainstay of initial treatment. Some patients may benefit from bisphosphonates after fluids, with the consultation of oncology and endocrine. Hemodialysis can be considered for patients with cardiac dysrhythmias or severe neurologic symptoms, or if large volumes of fluids cannot be tolerated.

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Background:

• Monkeypox virus (MPXV) has two distinct genetic clades (subtypes of MPXV), I and II, which are endemic to central and west Africa, respectively. 
• The global mpox outbreak that began in 2022 is caused by MPXV II
• The recent outbreak in Democratic Republic of Congo (DRC) is caused by MPXV I

What’s new?

• Democratic Republic of Congo (DRC) has reported more than 22,000 suspect cases of MPXV I since January 1, 2023 (annual median of 3,767 suspect MPXV I cases in prior 6 years)
• Largest number of yearly suspected MPXV I cases ever recorded 
• More widespread than any previous outbreak, resulting in transmission to neighboring countries [Republic of the Congo (ROC), the Central African Republic (CAR), Burundi, Rwanda, and Uganda].

Who is at risk?

Patients with epidemiologic characteristics and lesions or other signs and symptoms consistent with mpox. This includes anyone with travel to DRC or any of its neighboring countries (ROC, CAR, Rwanda, Burundi, Uganda, Zambia, Angola, Tanzania, and South Sudan) in the previous 21 days.

What to look for? 

• Rash that may be located on the hands, feet, chest, face, mouth, anus or near the genitals
• Lesions are firm or rubbery, well-circumscribed, deep-seated, and often develop umbilication (see below).

(Above photos from https://www.cdc.gov/poxvirus/mpox/clinicians/clinical-recognition.html)

• Lesions progress through four stages—macular, papular, vesicular, to pustular—before scabbing over and desquamation. They are often described as painful until the healing phase when they become itchy (crusts).
• Fever, chills, swollen lymph nodes 
• Fatigue, myalgia (muscle aches and backache), headache
• Respiratory symptoms like sore throat, nasal congestion, and cough
• Illness lasts 2-4 weeks
• Once all scabs have fallen off and a fresh layer of skin has formed, a person is no longer contagious.

What to do?

If mpox is suspected in a patient:

• Isolate the patient in a single patient room (no special air filtration is required).
• Use PPE (Gown, gloves, eye protection, and NIOSH-approved particulate respirator equipped with N95 filters or higher).
• Intubation and any procedures likely to spread oral secretions should be performed in an airborne infection isolation room.
• Notify your local health department immediately.
• Evaluate all suspected cases related to DRC or its neighboring countries with laboratory testing (rather than clinical diagnosis alone). 
• Counsel patients about staying away from other people and not sharing things they have touched with others; and cleaning and disinfecting the spaces they occupy regularly to limit household contamination.
• Recommend mpox vaccine to asymptomatic close contacts of cases of MPXV.
• Offer treatment with oral tecovirimat (TPOXX), available through the STOMP Trial. To enroll in STOMP, in the US call 1-855-876-9997.

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When it comes to walking, recent research and public health strategies have focused on how much you do that helps. This idea frequently comes up in the form of the 10,000 step goal.

A recent study in the British Journal of Sports Medicine found that walking between 9,000 and 10,000 steps/day could reduce the risk of death by 39% and cardiovascular disease by 21%.

For both outcomes (all-cause mortality and incident CVD), approximately 50% of the benefit was achieved between 4,000-4,500 steps per day.

Study accessed data on greater than 72,000 individuals (avg age 61, 58% female) using accelerometer data over an average of 6.9 years.

Instead of volume, a recent study in the same journal looked at the benefits of walking speed. 

The study looked at pooled data from 10 studies involving more than 500,000 people from the U.S., Japan and the U.K. 

Walking speed definitions:

Easy or casual walking - less than 2 mph. 

Average or normal pace was defined as 2-3mph.

A “fairly brisk” pace was 3-4 mph 

A “brisk/striding walking pace” was greater than 4mph 

Compared with people who walked at a casual/easy speed, those who walked at a normal/avg speed (2–3 mph) had a 15% lower risk of Type 2 diabetes. 

Walking at a fairly brisk pace (3–4 mph) was associated with a 24% lower risk of Type 2 diabetes.

Walking at a brisk or striding pace (over 4 mph) was associated with a 39% reduced risk of Type 2 diabetes.

Globally, 537 million adults have type 2 diabetes, a figure that is expected to reach 783 million by 2045.

Take home: Consider recommending tips on walking pace and distance for our sedentary patient population to optimize health.

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“I’m not going to the hospital, my father died in a hospital.”

In planning a study it’s a good practice to consider what confounding variables you may need to look out for.

Confounding variables are associated with the predictor (independent) and outcome (dependent) variables, but they are not in the causal chain. In the above example, disease is likely the predictor variable, death is the outcome variable, and going to the hospital is a confounder. Of course, this assumes the death was not iatrogenic; then the hospital would be in the causal chain.

Patients may be selected for interventions based on severity of disease, functional status, education level, and other factors, and these may be confounders.

Confounding can be addressed at the design stage, by:

• Specification – excluding patients with the confounder (often not feasible)
• Matching – selecting cases and controls matched by confounding variable levels
• Randomization – randomly select patients for an intervention and hope confounding variables will balance out

It can be addressed in the analysis stage by:

• Stratification – analyzing data in strata defined by confounding variable levels
• Adjustment – mathematically adjusting for the confounding variable (usually by regression)

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Previous literature has shown that there is a survival difference between White and Black palpitations with regards to out of hospital cardiac arrest (OHCA) in the US.

This study looked at OHCA variables and outcomes among 5 racial/ethnic groups (White, Black, Asian, Hispanic, and Pacific Islander).  Data was collected from the CARES registry from 3 racially diverse counties.  The adjusted risk ratio for survival to hospital discharge was lower in all 4 other groups compared to patients where data entry identified the patient as White.  The risk difference for positive neurologic outcomes was also lower among Black, Asian, Hispanic, and Pacific Islander patients.

When looking at variables associated with the cardiac arrests, there were differences between the groups with regards to response location and bystander CPR.

Bottom line: Cardiac arrest recognition and CPR education needs to be inclusive of all racial/ethnic groups and focus on areas where disparities exist.

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Euglycemic DKA (eDKA) is a medical emergency requiring prompt attention. It is caused by an imbalance of insulin and glucagon leading to ketone accumulation (1-3). In addition to typical risk factors for DKA, those for eDKA include SGLT-2 inhibitor use and pregnancy, with 30% of DKA cases in pregnancy presenting euglycemic (4, 5).

eDKA presents with an anion gap metabolic acidosis, ketosis/ketonuria, & blood glucose less than 250 mg/dL.

Diagnosis requires ruling out other causes of anion gap metabolic acidosis, including toxic ingestions.

The cornerstone of eDKA management is ensuring enough dextrose to allow needed insulin administration to reverse ketone accumulation.

Pitfalls

• Not giving enough insulin to reverse ketosis due to concern about low blood sugars
• Not giving enough dextrose to support sufficient insulin dosing
• Not uptitrating insulin for refractory acidosis caused by eDKA

Pearls

• Start insulin with at least 0.05 units/kg/hour along with IV dextrose (3,5,7,9)
• Start IV dextrose at 5-10 g/hr (9). This will be 100-200 mL/hr of a 5% dextrose solution (dextrose should be added to either normal or ½ normal saline to avoid causing hyponatremia!)
  • Dextrose concentrations: D5 = 50 g/L || D10 = 100 g/L || D20 = 200 g/L
• Euglycemic DKA may present WITHOUT ketonuria if the patient is on an SGLT-2 inhibitor (7,8) – send a beta hydroxybutyrate!
• eDKA is most common in the first two months of SGLT-2 inhibitor use, but can happen at any time (6)

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To obtain a posterior shoulder view: Have the patient sit up with the back of the bed down. Position the curvilinear probe in the posterior aspect of the shoulder with the probe parallel to the patient bed, at the level just below the scapular spine and the marker towards the patient's left. You can have the patient rotate their arm to help you visualize the movement of the humeral head.

In the normal anatomy, the humeral head should be at the level of the glenoid (this is a patient's left shoulder):

Locate the glenohumeral joint space.  You can evaluate the GH joint for effusion, perform joint arthrocentesis/injection and look for signs of shoulder dislocation. 

If you are evaluating for signs of a dislocation:

Posterior dislocation: the humeral head will be more SUPERFICIAL in the image than the scapular spine

Anterior dislocation: the humeral head will be DEEPER in the image than the scapular spine.

Deciding who needs exposure to radiation after blunt head injury has been looked at by both the Canadian Head Injury Guidelines as well as NEXUS.  This website has excellent graphics outlining the rules. Note age over 65 alone is predictive of significant intracranial injury. All recent studies indicate age over 65 even with a low suspicion mechanism such as fall from standing is still a significant risk for intracranial pathology.

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This retrospective study found that while overall rates of antibiotic prescriptions for viral URIs were low (that's good!), patients identified as non Hispanic white were prescribed antibiotics, despite guidelines advising against them,  at a higher rate than non white patients (that's bad).  It also found that in areas of socioeconomic deprivation, the prescribing rates were lower across all races than in more affluent areas (that's good and bad!)

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This was an observational study where ultrasound was used to evaluate if the diaphragm came into view at the 5th intercoastal space (ICS) at the midaxillary line in pediatric patients during maximal respiration. A convenience sample of pediatric patients who presented to the an academic pediatric emergency department was used.

In 10.3% of patients, the diaphragm crossed the 5th ICS during normal respirations and 27.2% crossed during maximal respirations.  This was a more common occurrence on the right compared to the left.  An increase in body mass index was also associated with an increased risk of the diaphragm crossing the during both tidal respiration and maximal respirations.

Bottom line: Using a blind insertion of a chest tube at the 5th ICS, midaxillary line in the pediatric patient poses a not insignificant risk of piercing the diaphragm.  this study recommends using ultrasound prior to chest tube placement.

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A study looking at patients over age 65 with head injuries from falls assessed the association of alcohol use with severity of injury. The alcohol use was self-reported which does limit the findings. The study found “Of 3128 study participants, 18.2% (n = 567) reported alcohol use: 10.3% with occasional use, 1.9% with weekly use, and 6.0% with daily use.”  Those daily drinkers had a higher incidence of intercranial injuries.
The authors concluded: “Alcohol use in older adult emergency department patients with head trauma is relatively common. Self-reported alcohol use appears to be associated with a higher risk of ICH in a dose-dependent fashion. Fall prevention strategies may need to consider alcohol mitigation as a modifiable risk factor.”

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