Category: Pharmacology & Therapeutics
Keywords: Insulin, Hyperkalemia, Dextrose (PubMed Search)
Posted: 11/6/2017 by Wesley Oliver
(Updated: 11/27/2024)
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Strategies for Hyperkalemia Management | |
Stabilize cardiac membrane | Calcium gluconate |
Intracellular movement in skeletal muscles | Albuterol Sodium Bicarbonate Insulin |
Potassium excretion | Loop Diuretics Kayexalate Patiromer (chronic use only) |
Potassium removal | Dialysis |
Insulin mechanism of action for hyperkalemia:
· Binds to skeletal muscle receptors
· Increased activity of the sodium-potassium adenosine triphosphatase and glucose transporter GLUT4
· Glycemic response occurs at lower levels of insulin
· Potassium transport activity increases as insulin levels increase
Patients with insulin resistance due to type-2 diabetes do not become resistant to the kalemic effects of insulin.
Hypoglycemia following insulin administration for hyperkalemia:
· Occurs 1-3 hours post dose, even with initial bolus of dextrose
· The amount of glucose is insufficient to replace the glucose utilized in response to the administered dose of insulin
· Insulin’s half-life is increased in ESRD leading to longer duration of action
A systematic review of 11 studies regarding insulin dosing for hyperkalemia:
· 22 patients (18%) experienced hypoglycemia
· Studies that only gave 25 grams (1 amp) of dextrose had the highest incidence of hypoglycemia (30%)
Tips:
· Consider insulin dose reduction in patients with renal failure
· Use an order set to ensure patients receive appropriate POC glucose monitoring to detect delayed onset of hypoglycemia
· Dextrose 50% (25 grams) should be given to all patients with pre-insulin BG <350 mg/dL
Subsequent PRN dextrose 50% (25 grams) should be used to maintain BG >100 mg/dL after insulin administration
References:
1. Sterns RH, Grieff M, Bernstein PL. Treatment of hyperkalemia: something old, something new. Kidney International 2016;89(3):5460554.
2. Harel Z, Kamel KS (2016) Optimal Dose and Method of Administration of Intravenous Insulin in the Management of Emergency Hyperkalemia: A Systematic Review. PLoS ONE 11(5): e0154963. doi:10.1371/journal.pone.0154963
Category: Geriatrics
Keywords: elderly, psychiatry, mental health, screening (PubMed Search)
Posted: 11/5/2017 by Danya Khoujah, MBBS
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Arias, S. A., Boudreaux, E. D., Segal, D. L., Miller, I., Camargo, C. A. and Betz, M. E. (2017), Disparities in Treatment of Older Adults with Suicide Risk in the Emergency Department. J Am Geriatr Soc, 65: 2272–2277. doi:10.1111/jgs.15011
Category: Critical Care
Posted: 11/3/2017 by Ashley Menne, MD
(Updated: 11/27/2024)
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Core Temp <32 degrees leads to impaired shivering and confers increased risk for malignant ventricular dysrhythmias. Core Temp <28 degrees substantially increases risk of cardiac arrest.
If in cardiac arrest:
If perfusing rhythm:
Consider addition of more invasive rewarming techniques in those with hemodynamic/cadiac instability or without access to VA ECMO/CPB:
Consider stopping resuscitation efforts if/when:
Douglas J. A. Brown, Hermann Brugger, Jeff Boyd, Peter Paal. (2012). Accidental Hypothermia. New England Journal of Medicine. https://doi.org/10.1056/NEJMra1114208
Category: Toxicology
Keywords: Hemodialysis (PubMed Search)
Posted: 11/2/2017 by Kathy Prybys, MD
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The cornerstone treatment of poisoning is removal of the toxin from the patient. This can be accomplished before absorption into the body by decontamination methods (dermal or gastrointestinal) or after absorption by blocking metabolism of parent compound, displacing drugs from receptors, binding toxins with neutralizing agents (chelators, Fab fragments), or enhancing elimination by dialysis. Toxins that are ideal candidates for dialysis include substances that are low molecular weight, have low volume of distribution (stay in the blood stream), or low protein binding. Toxins most commonly treated with dialysis are:
Category: Orthopedics
Keywords: Muscle injury, splinting (PubMed Search)
Posted: 10/28/2017 by Brian Corwell, MD
(Updated: 11/27/2024)
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Quadriceps Contusion
Mechanism: Blunt trauma to the anterior thigh (frequently football helmet or opponents knee)
Usually involves the anterior quadriceps (rectus femoris and vastus intermedius)
Pain on passive stretch and active contraction
Can develop large hematomas
Loss of knee flexion is a poor prognosticator
Complication: Myositis Ossificans (MO) (5-17%)
Increased risk with delay in treatment > 3 days
Radiographs can lag. Ultrasound in more sensitive
Painful firm area in region of contusion occurring 2 to 3 weeks post injury
http://fifamedicinediploma.com/wp-content/uploads/2015/12/myositis_ossificans_lateral-1.jpg
Prompt treatment….key to good outcome and earlier return to sports
Large hematoma can be aspirated. NSAIDs may reduce edema and risk of MO. Splinting
Place quadriceps in 120 degrees of flexion for 24 hours following injury (keep muscle lengthened)
https://upload.orthobullets.com/topic/3103/images/quad%20contusion_moved.jpg
Category: Pediatrics
Keywords: ARDS, oxygenation index, OI, PALICC, acute lung injury, respiratory distress, PARDS (PubMed Search)
Posted: 10/27/2017 by Mimi Lu, MD
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Some pediatric practitioners have adopted the oxygenation index (OI) ([FiO2 × mean airway pressure (Paw) × 100]/ PaO2) or oxygen saturation index (OSI) ([FiO2 × Paw × 100]/ SpO2) to assess hypoxemia in children instead of P/F ratios because of the less standardized approach to positive pressure ventilation in children relative to adults.
OI can be used in pediatric patients to define severity of Acute Respiratory Distress Syndrome (ARDS) in patients receiving invasive mechanical ventilation and assess for potential ECMO treatment.
In contrast, the P/F ratio should be used to diagnose Pediatric ARDS for patients receiving noninvasive continuous positive airway pressure [CPAP] or bilevel positive airway pressure [BiPAP]) with a minimum CPAP of 5 cm H2O.
Oxygen Index (OI) = FiO2 x MAP x 100
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PaO2
Category: Toxicology
Keywords: strychnine (PubMed Search)
Posted: 10/26/2017 by Hong Kim, MD
(Updated: 10/27/2017)
Click here to contact Hong Kim, MD
Her first book “The mysterious affair at Styles,” Agatha Christie introduced her lead detective in her novels, Hercule Poirot - the Belgian detective. She also described the death of Mrs. Emily Inglethorp by strychnine.
Strychnine is found in a disc-like seed of strychnos nux-vomica, a tree native to tropical Asia and North Australia.
It is currently used as rodenticide (moles and gophers), in Chinese herbal medicine and a traditional remedy in Cambodia.
Strychnine inhibits binding of glycine (a major inhibitory neurotransmitter in spinal cord) to Cl-channel resulting in identical clinical syndrome – seizure-like generalized muscle contraction with normal mental status – as tetanus toxin. Tetanus toxin inhibits the release of presynaptic glycine in the spinal cord.
Management
Goal: decrease muscle hyperactivity
Category: Neurology
Keywords: weakness, infection, paralysis, intubation, influenza, vaccine (PubMed Search)
Posted: 10/25/2017 by Danya Khoujah, MBBS
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It's respiratory infection and flu vaccine season! Time to brush up on Guillain-Barré Syndrome..
- It is the most common cause of acute or subacute flaccid weakness worldwide
- 70% of cases are preceded by an infection in the past 10-14 days, but most are minimized or forgotten by the patient. 40% of these infections are by Campylobacter jejuni.
- 30% develop respiratory failure requiring intubation and ventilation
- Half of the patients will develop their maximum weakness by 2 weeks, most will develop it by 4 weeks.
Donofrio PD. Guillain-Barré Syndrome. Continuum 2017;23(5):1295–1309.
Category: Gastrointestional
Posted: 10/21/2017 by Michael Bond, MD
(Updated: 11/27/2024)
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Infectious Diarrhea:
Have your wondered what you should do with patients that you suspect have infectious diarrhea. Well the IDSA has updated their 2001 guidelines for the management of infectious diarrhea. The TAKE HOME Points are:
You can find all the recommendations at https://academic.oup.com/cid/article/doi/10.1093/cid/cix669/4557073/2017-Infectious-Diseases-Society-of-America
Category: Pediatrics
Keywords: Vomiting, pediatric, medication (PubMed Search)
Posted: 10/20/2017 by Jenny Guyther, MD
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Within the first hour after administration, ondosterone, metoclopramide and bromopride were equally efficacious. At the 6 hour and 24 hour period after receiving the initial dose of medication, ondansetron was statistically superior to bromopride (not available in the US) and metoclopramide. There were no reported side effects in the ondansetron group (including diarrhea or sedation).
This was a randomized control trial of children 1 year to 12 years seen in the pediatric emergency department in Brazil for vomiting and given intramuscular bromopride (0.15mg/kg to a maximum of 10 mg), metoclopramide (0.15mg/kg to a maximum of 10 mg), or ondansetron (0.15mg/kg to a maximum of 8 mg). 175 children were included.
Epifanio et al. Bromopride, metoclopramide, or ondansetron for the treatment of vomiting in the emergency in the pediatric emergency department: a randomized control trial. J Pediatr 2017. Article in Press.
Category: Toxicology
Keywords: Arsenic poisoning (PubMed Search)
Posted: 10/19/2017 by Hong Kim, MD
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Agatha Christie is an English crime novelist who frequently used poisons in her books to murder the victims. In her book, Murder is Easy, Ms. Christie uses arsenic/arsenic trioxide to kill several characters.
Primary source of arsenic in general population is contaminated food, water and soil. Arsenic exists in several forms: elemental, gaseous (arsine), organic and inorganic (trivalent or pentavalent).
Arsenic trioxide has also been used to treat acute promyelocytic leukemia in China; it’s use in other leukemia, lymphoma, and other solid tumors are currently being investigated.
Arsenic primarily inhibits the pyruvate dehydrogenase complex and multiple other enzymes involved in the citric cycle/oxidative phosphorylation, resulting in mitochondrial dysfunction.
Acute toxicity of arsenic after ingestion
Management
Category: Critical Care
Posted: 10/17/2017 by Mike Winters, MBA, MD
(Updated: 11/27/2024)
Click here to contact Mike Winters, MBA, MD
Improving CPR Performance
Nassar BS, et al. Improving CPR performance. Chest. 2017. {epub ahead of print]
Jentzer JC, et al. Improving survival from cardiac arrest: A review of contemporary practice and challenges. Ann Emerg Med. 2016; 68:678-89.
Category: Orthopedics
Keywords: Knee pain (PubMed Search)
Posted: 10/14/2017 by Brian Corwell, MD
(Updated: 11/27/2024)
Click here to contact Brian Corwell, MD
Complete or incomplete separation of the articular cartilage and subchondral bone
-70% occur at the lateral aspect of the medial femoral condyle
-Also seen in the talar dome and capitellum
Repetitive overloading leads to fragmentation and separation from surrounding bone
Prognosis better in kids than in adults
http://www.eorif.com/KneeLeg/Images/OCD4w.jpg
CC: Vague difficult to localize activity related pain and swelling. Mechanical symptoms only if loose body is present
PE: Wilson’s test
Internal tibial rotation and knee extension impinges the tibia on the OCD lesion causing pain. Pain abates with external rotation and flexion.
https://www.youtube.com/watch?v=e7zrKo41Pos
Plan of care: Limit activity and trial period of non-weight bearing for 6 weeks.
50% resolve in 10 to 18 months with conservative care.
Detached, loose or unstable fragments or failure of non-operative care will need surgery
Category: Pediatrics
Keywords: Trauma, hematuria, kidney injury (PubMed Search)
Posted: 10/13/2017 by Mimi Lu, MD
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Category: Toxicology
Keywords: Cannabinoid, cyclic vomiting, Capsaicin (PubMed Search)
Posted: 10/12/2017 by Kathy Prybys, MD
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Cannabinoid hyperemesis is a syndrome (CHS) characterized by severe intractable nausea, cyclical vomiting, and abdominal pain associated with chronic marijuana abuse. It is often a underrecognized cause of cyclic vomiting syndrome. Despite well established anti-emetic properties of marijuana, paradoxical effects on the GI tract exist through cannabinoid receptors which exert their neuromodulatory properties in the central nervous system and the enteric plexus. Multiple theories of mechanism of CHS are in the literature. Diagnosis is based on the following clinical criteria:
Acute care goals are to treat dehydration and terminate nausea and vomiting. Administration of intravenous fluids, dopamine antagonists, topical capsaicin cream, and avoidance of narcotic medications are recommened treatment measures. Benzodiazepines followed by haloperidol and topical capsaicin are reported to be most effective. Capsaicin activates the transient receptor potential vanilloid 1 receptors (TRPV1) which impairs substance P signalling in the area postrema and nucleus tract solitarius similar to noxious stimuli, such as heat.
Cannabinoid Hyperemesis Syndrome: Diagnosis, Pathophysiology, and Treatment-a Systematic Review. Sorensen CJ, DeSanto K, et al. J Med Toxicol. 2017 Mar;13(1):71-87.
Cannabinoid Hyperemesis and Compulsive Bathing: A Case Series and Paradoxical Pathophysiological Explanation. Patterson D, Smith E, et al. Am Board Fam Med. 2010 Nov-Dec; 23(6): 790-793.
Pharmacologic treatment of cannabinoid hyperemesis Syndrome: A systematic review. Pharmacotherapy. Dezieck L, Hafez Z. 2017 Jun:37(6):725-734.
Resolution of cannabis hyperemesis syndrome with topical capsaicin in the emergency department: a case series. Dezieck L, Hafez Z, et al. Clin Toxicol (Phila). 2017 Sep;55(8):908-913.
Category: Neurology
Keywords: traumatic brain injury, TBI, fall, subdural hematoma, SDH, elderly (PubMed Search)
Posted: 10/11/2017 by WanTsu Wendy Chang, MD
Click here to contact WanTsu Wendy Chang, MD
Traumatic brain injury (TBI) is associated with close to half of major trauma admissions in adults over age 65 in the U.K.
Falls accounted for 85% of all TBIs, while 45% of patients had subdural hematomas (SDH).
More than 3/4 of patients were treated conservatively, though outcomes were not significantly better than those who underwent neurosurgical intervention.
Higher age is associated with higher mortality and greater disability.
Bottom Line: Trauma in older adults is increasing and fall prevention is important in reducing significant injuries.
Hawley C, Sakr M, Scapinello S, et al. Traumatic brain injuries in older adults - 6 years of data for one UK trauma centre: retrospective analysis of prospectively collected data. Emerg Med J 2017;0:1-8.
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Category: Critical Care
Keywords: liver failure, dialysis, MARS, Molecular Adsorbent Recirculating System (PubMed Search)
Posted: 10/10/2017 by Kami Windsor, MD
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Molecular Adsorbent Recirculating System (MARS) is an artificial liver support system colloquially known in the medical field as "dialysis for the liver."
Take-Home:
1. Consider MARS in your patient with severe acute liver failure due to potentially reversible/recoverable etiology
2. Know if and where MARS is offered near you
(http://findbesttreatment.com/images/healthnet_dialyse_schema.gif)
Molecular Adsorbent Recirculating System (MARS) is an artificial liver support system colloquially known in the medical field as "dialysis for the liver."
Its use demonstrates apparent effective replacement of liver function, with consistently-proven improvements in hemodynamics, hepatic encephalopathy, hepatorenal syndrome, drug clearance, hyperbilirubinemia, and other markers of hepatic homeostasis.
It has been repeatedly demonstrated to work well as a short-term bridge to liver recovery or liver transplant in severe ALF of various causes, especially those that are generally reversible with support and time severe trauma, toxic ingestions, and acute alcoholic hepatitis.
Mortality benefit remains unclear and may be dependent on the subtype of acute liver failure. Most of the current literature is made up of case reports, or case studies with small study populations. In acute on chronic liver failure, the 23-patient randomized, controlled RELIEF trial failed to show survival advantage at 28 days. Gerth et al, however, found a 14-day mortality benefit in ACF patients by retrospective analysis, which may indicate that MARS use as a bridge to transplant is the most appropriate utilization in this patient population.
Category: Pharmacology & Therapeutics
Keywords: antipyretic, sepsis, fever (PubMed Search)
Posted: 10/7/2017 by Ashley Martinelli
(Updated: 11/27/2024)
Click here to contact Ashley Martinelli
Fever occurs in 40% of patients with sepsis. Historically, there has been conflicting evidence of whether patient outcomes improve with antipyretic therapy.
A recent large meta-analysis assessed the effect of antipyretic therapy on mortality of critically ill septic patients. The analysis included 8 randomized studies (1,531 patients) and 8 observational studies (17,432 patients) that assessed mortality of septic patients with and without antipyretic therapy.
The authors found no difference in mortality at 28 days or during hospital admission. There was also no difference in shock reversal, heart rate, or minute ventilation.
As expected, they found a statistically significant reduction in posttreatment body temperature (-0.38°C, 95% IC -0.63 to -0.13) in patients who received antipyretic therapy. NSAIDs and cooling therapies were more effective than acetaminophen, however no agent or dosing information was provided and only one study included physical cooling therapies.
Bottom Line: Antipyretic therapies do not reduce mortality in patients with sepsis, but they may improve patient comfort by reducing body temperature.
Drewry AM, et al. Antipyretic therapy in critically ill septic patients: a systematic review and meta-analysis. Crit Care Med 2017;45:806-813.
Category: Pediatrics
Keywords: Pediatrics, Bronchiolitis, Respiratory Decompensation, Risk factors (PubMed Search)
Posted: 10/6/2017 by Megan Cobb, MD
Click here to contact Megan Cobb, MD
Bronchiolitis season will soon be upon us. Here are some risk factors for children under 2 y/o with bronchiolitis, who may be more likely to suffer respiratory decompensation:
1. Age under 9 months
2. Black race
3. Hypoxia documented in the ED
4. Persisent accessory muscle use.
Bottom Line: Consider providing respiratory support sooner than later in bronchiolitic infants with risk factors for decompensation. For HFNC, start at 1.5 - 2.0 L/kg/min, and titrate to work of breathing and 02 saturations.
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Pathophysiology: Bronchiolitis is a disease process that leads to inflammation of lower airways, causing bronchiolar edema, epithelial hyperplasia, mucus plugging, and air trapping or atelectasis. Common viral causes include RSV, Human Metapneumovirus, Rhinovirus, Influenza, and Parainfluenza.
Clinical Course: For most strains, the disease course is often 5-7 days with the worst days being 3-5. The disease process can last longer, especially in neonates. The predominant presenting symptoms are often rhinorrhea, low grade fevers, and cough, but apnea can be the primary symptom in younger infants. As a result of increased work of breathing, PO feeding tolerance decreases and leads to dehydration.
Treatment: Primarily supportive care with suctioning, hydration, supplemental oxygen via standard NC, HFNC, and in severe cases BiPAP, CPAP or intubation. Trial of bronchodilator is often used, but there is no role for repeated bronchodilator use if no benefit is seen in pre and posttreatment respiratory effort. Hypertonic saline is not recommended for routine use in the ED. Corticosteroids have no role for routine use in viral bronchiolitis, either.
Category: Toxicology
Keywords: Capsaicin, hunan hand, chili peppers (PubMed Search)
Posted: 10/6/2017 by Kathy Prybys, MD
Click here to contact Kathy Prybys, MD
Hunan hand syndrome is a painful contact dermatitis that frequently presents in cooks and chili pepper workers after preparing or handling chili peppers. Contact with other body parts gives rise to the terms: "Hunan nose" ''Hunan eye",and "Chili Willie". Capsaicin, found in the fruit of plants from the genus Capsicum such as red chili peppers, jalapeños, and habaneros, is a hydrophobic, colorless, odorless compound that binds with pain receptors causing the sensation of intense heat or burning. The "heat" or pungency of a peppers is measured in Scoville heat units (SHU), the number of times a chili extract must be diluted with water to lose heat. Habanero peppers generate 30,000 SHU. Even at low concentrations capsaicin is a skin irritant. It is the primary ingredient in pepper spray used in law enforcement and in personal defense sprays.
Treatment consists of decontamination with water irrigation for opthalmic exposure and milk or antacids for dermal or gastrointestinal exposure. Burning can be recurrent and of of long duration depending on tissue penetration. Topical anesthetic especially for the eye and cool compresses for the skin can relieve pain. Parodoxically capsaicin is used as a topical analgesic medication for local pain relief from muscle pain, itching, and painful neuropathies (diabetic, postherpetic). Capsaicin initially causes neuronal excitation followed by a long-lasting refractory period due to depletion of substance P, during which neurons are no longer responsive to a large range of stimuli and thus are desensitized.