UMEM Educational Pearls

Title: Deadly in a drop!

Category: Toxicology

Keywords: Botulinum, Dimethylmercury, VX, Tetrodotoxin (PubMed Search)

Posted: 8/17/2017 by Kathy Prybys, MD (Updated: 8/31/2017)
Click here to contact Kathy Prybys, MD

Botulinum
  • Most poisonous substance known to man
  • LD50 oral dose 1 mcg/kg
  • Heat labile single polypeptide chain undergoes proteolytic clevage irreverisibly binds  and blocks cholinergic transmission causing a deadly neuroparalytic syndrome
  • Rx: Botulin antitoxin (equine derived against Clostriduim botulinum A,B,E)
Dimethylmercury (CH3)2 Hg
  • Highly toxic, restricted availability is rapidly absorbed and metabolized to methylmercury crosses CNS
  • LD50 of 50 mcg/kg means a dose as little as 0.1ml can result in severe poisoning
  • Death of Darmouth inorganic chemist Karen Wetterhahn who spilled a few drops on back of her latex gloved hand, quickly permeated, and absorbed causing severe neurotoxocity and death 10 months later
  • Rx: Chelation

VX ("venomous agent X") 

  • Organophosphate nerve agent has been used as chemical weapon
  • Colorless, odorless, low volatility, and high lipophilicity
  • LD50 of 0.04mg/kg (10 mg). Death can occur within 15 minutes after absorption
  • Blocks acetylcholinesterase enzyme causing excess accumulation of acetylcholine at the neurojunction and cholinergic poisoning
  • Rx: Decontamination, Atropine, 2-PAM
Tetrodotoxin
  • 100 fresh and salt water varieties (pufferlike fish/blue ringed octopus, frogs)
  • Heat stable, water soluble found in fish skin, liver, ovaries,intestine, and muscle
  • 25 mg (0.000881 oz) expected to be lethal to a 75 kg person
  • Neurotoxicity by inhibition of Na-K pump and blockade neuromuscular transmission
  • Rx: Supportive measures

LD50 expresses the dose at which 50% of exposed population will die as a result of exposure.

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Background: Sedation and analgesia are key components for mechanically ventilated patients. While significant data exists regarding how to manage sedation and analgesia in the ICU setting, very little data exists on management in the ED.

Data: A prospective, single-center, observational study of mechanically-ventilated adult patients used linear regression to identify ED sedation practices and outcomes, with a focus on sedation characteristics using the Richmond Agitation-Sedation Scale (RASS).

Findings:

  • 15% of intubated patients had no sedation or analgesia ordered
  • 64% of intubated patients were documented as deeply-sedated (RASS -3 to -5)
  • Deep sedation was not only associated with more ventilator days, but also increased mortality, with an adjusted OR of 0.77 (95% CI 0.54-0.94) favoring patients with lighter sedation.


Bottom line:  Avoid early deep sedation in your intubated patients as this may be directly associated with increased mortality. Instead, a goal RASS of 0 to -2 should be appropriate for most non-paralyzed, mechanically-ventilated ED patients, extrapoloating from ICU guidelines.

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Title: Concussion outcome predictors

Category: Orthopedics

Keywords: Concussion recovery (PubMed Search)

Posted: 8/26/2017 by Brian Corwell, MD (Updated: 11/27/2024)
Click here to contact Brian Corwell, MD

There is tremendous interest in identifying factors that may influence outcome from sports related concussion.

The strongest predictor of slower recovery is the severity of symptoms in the 1-2 days post injury

     -Fewer Sx's in this time period predict a quicker recovery

Pre injury history of mental health problems, depression or migraine headaches predict a longer recovery course

Teenagers might be more vulnerable to having persistent symptoms with greater risk for girls than boys

Having a prior concussion is a risk for having a future concussion

The large majority of injured athletes recover from a clinical perspective within the first month of injury many within the first 10 days

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Title: What about Anaphylaxis in kids? (submitted by Yitschok Applebaum, MD)

Category: Pediatrics

Keywords: allergic reaction, anaphylaxis, auto-injector, epi-pen (PubMed Search)

Posted: 1/27/2017 by Mimi Lu, MD (Updated: 8/25/2017)
Click here to contact Mimi Lu, MD

What if you were out in public and a 1 year old child (est 10 kg) suddenly develops anaphylaxis but you only have an epinephrine auto-injector with the “adult” dose of 0.3 mg.  Is it safe to give?

Anaphylaxis is a life threatening emergency with mortality of up to 2% [1]. Early recognition is imperative and administration of timely Epinephrine is the single most important intervention [2]. While providers may be hesitant to administer epinephrine in older patients due to fear of precipitating adverse cardiovascular events, they may also hesitate in younger patients due to fear of overdose. 

Iimmediate administration with any dose available is recommended because:

  • the risks of untreated anaphylaxis are greater than the risk of over-treating with epinephrine.
  • 20% of Anaphylaxis patients require a second dose of Epinephrine [3].
  • The recommended IM dose of 0.01mg /kg was determined arbitrarily.
  • The vast majority of epinephrine overdoses are via IV injection at doses 100 - 1000 fold the recommended  IV dose [4]

Bottom line:

There are no absolute contraindications (including age) for epinephrine in patients with anaphylaxis.  Give the initial dose IM into the anterolateral thigh.

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Title: Idarucizumab for Dabigatran reversal 2.0

Category: Toxicology

Keywords: dabigatran reversal, Idarucizumab (PubMed Search)

Posted: 8/25/2017 by Hong Kim, MD
Click here to contact Hong Kim, MD

Full cohort analysis idarucizumab for dabigatran associated bleeding was recently published in NEJM.

This study evaluated the laboratory correction of elevated ecarin clotting time or diluted thrombin time induced by dabigatran and time to either cessation of bleeding (Group A: patients with GI bleeding, traumatic bleeding, or ICH) or time to surgery (Group B: patients requiring surgical intervention within 8 hours).

Findings

Group A (n=301): Median time to the cessation of bleeding was 2.5 hours in 134 patients.

HOWEVER:

  • Bleeding cessation could not be determined in 67 patients
  • Cessation of bleeding could not be assess in 98 patients with ICH
  • Bleeding stopped spontaneously in 2 patients.

Group B (n=202): Median time to intended surgery after infusion of idarucizumab was 1.6 hours.

  • Normal hemostasis in 184 patients (93.4%), mildly abnormal in 10, and moderately abnormal in 3.
  • Many received PRBC and other blood products during surgery

Laboratory markers:

100% reversal of abnormal ecarin clotting time or diluted thrombin time within 4 hours after the administration

Mortality

  • 5 Day: Group A: 6.3% vs. Group B: 12.6%
  • 30 Day: Group A: 13.5% vs. Group B: 12.6%
  • 90 Day: Group A: 18.8% vs. Group B: 18.9%

 

Conclusion

Authors concluded thate idaurcizumab is an "effective" reversal agent for dabigatran.

Overall, the findings are more promising compared to the interim analysis that was published in 2015.

 

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Rapid detection of bacterial meningitis using point-of-care glucometer

  • CSF:blood glucose ratio is a useful characteristic in differentiating bacterial meningitis from viral meningitis. 
  • Normal CSF glucose is at least 2/3 of serum glucose level.
  • In bacterial meningitis, CSF:blood glucose ratio is usually <0.4
  • Rousseau et al. conducted a study comparing CSF:blood glucose ratio obtained using a bedside glucometer with the laboratory.
  • They found the optimal cutoff of CSF:blood glucose ratio using a bedside glucometer is 0.46 compared to 0.44 using the laboratory.
  • This proof-of-concept study suggests that a point-of-care glucometer can be used for rapid diagnosis of abnormal CSF:blood glucose ratio in the evaluation of meningitis.

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Hyponatremic Encephalopathy

  • Hyponatremic encephalopathy is a true emergency and due to hypoosmolar-induced cerebral edema.
  • In contrast to the asymptomatic patient with hyponatremia, treatment of hyponatremic encephalopathy is determined by symptoms and not the duration of hyponatremia.
  • Clinical manifestations include nausea, vomiting, headache, confusion, seizures, respiratory failure, and coma.
  • Hypertonic saliine is the treatment of choice
    • Administer 2 ml/kg 3% hypertonic saline (100 ml in many cases)
    • This will typically raise serum sodium 2 mEq/L
    • In most cases, a 4-6 mEq/L rise will reverse neurologic symptoms

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Title: Bacterial Meningitis in Pediatric Complex Febrile Seizures

Category: Pediatrics

Keywords: Febrile seizure, meningitis (PubMed Search)

Posted: 8/18/2017 by Jenny Guyther, MD (Updated: 11/27/2024)
Click here to contact Jenny Guyther, MD

Febrile seizures occur in children 6 months through 5 year olds.  A complex febrile seizure occurs when the seizure is focal, prolonged (> 15 min), or occurs more than once in 24 hours.

The prevalence of bacterial meningitis in children with fever and seizure after the H flu and Strep pneumomoniae vaccine was introduced is 0.6% to 0.8%.  The prevalence of bacterial meningitis is 5x higher after a complex than simple seizure.

From the study referenced, those children with complex febrile seizures who had meningitis all had clinical exam findings suggestive of meningitis.  More studies are needed to provide definitive guidelines about when lumbar punctures are needed in these patients.

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Title: Which patients with suicidal ideation are safe to discharge?

Category: International EM

Keywords: suicide, clinical policies, risk-assessment tools (PubMed Search)

Posted: 8/11/2017 by Jon Mark Hirshon, PhD, MPH, MD (Updated: 8/16/2017)
Click here to contact Jon Mark Hirshon, PhD, MPH, MD

In patients presenting to the ED with suicidal ideation, physicians should not use currently available risk-assessment tools in isolation to identify low-risk patients who are safe for discharge. The best approach to determine risk is an appropriate psychiatric assessment and good clinical judgment, taking patient, family, and community factors into account. (Level C Recommendation, based upon the quality of the research.) 

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Title: Catastrophic Antiphospholipid Syndrome

Category: Critical Care

Keywords: autoimmune, rheumatology, thrombosis, hematology (PubMed Search)

Posted: 8/15/2017 by Kami Windsor, MD
Click here to contact Kami Windsor, MD

Catastrophic Antiphospholipid Syndrome (CAPS):

A life-threatening “thrombotic storm” of multi-organ micro & macro thrombosis in patients with antiphospholipid syndrome (known or unknown).

Triggered circulating antibodies (usually by infection, but can be prompted by malignancy, pregnancy, and lupus itself) cause endothelial disruption and inflammation leading to prothrombotic state, commonly with SIRS response.

Mortality is high at an estimated 40%.

Confirm diagnosis with antiphospholipid antibody titers.

Treat ASAP with unfractionated heparin, corticosteroids, and Hematology consultation for plasma exchange and/or IVIG.

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Title: Pituitary Apoplexy

Category: Neurology

Keywords: pituitary apoplexy, subarachnoid hemorrhage, meningitis, headache, CT, MRI (PubMed Search)

Posted: 8/9/2017 by Danya Khoujah, MBBS (Updated: 11/27/2024)
Click here to contact Danya Khoujah, MBBS

Pituitary apoplexy is a sudden hemorrhage or infarction of the pituitary.
  • It most commonly occurs in patients with preexisting pituitary adenomas, but 3 out of 4 patients with pituitary adenomas are unaware of their diagnosis.
  • Patients may acutely present with thunderclap headache, with or without visual field deficits or cranial nerve dysfunction. They may also have meningeal symptoms due to extravasation of blood into the subarachnoid space.
  • Endocrine dysfunction is common but not readily diagnosed in the ED.
  • Symptoms may be triggered by some hormonal treatments (e.g. GnRH agonists for prostate CA), head trauma, angiographic procedures, or anticoagulation therapy.
  • CT is diagnostic in only one-third of cases, but can reveal the intrasellar mass in 80% of cases, and therefore should be the initial test. Blood may be missed in subacute cases.
  • MRI is the test of choice, with a sensitivity of over 90%.  

Bottomline: Keep pituitary apoplexy in your differential when considering SAH or meningitis, especially in the presence of risk factors, and have a low threshold to order an MRI. 

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Take Home Point: In patients with diabetic gastroparesis, haloperidol may be an effective adjunctive treatment to prevent hospitalizations and reduce opioid requirements. 

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Title: Should you order labs on that routine psychiatric patient?

Category: International EM

Keywords: Mental health, routine laboratory test, acute psychiatric patient (PubMed Search)

Posted: 8/2/2017 by Jon Mark Hirshon, PhD, MPH, MD
Click here to contact Jon Mark Hirshon, PhD, MPH, MD

Patients with psychiatric disorders are found globally, with a recent global burden of disease estimate that mental illness accounted for 32.4% of years lived with disability and 13.0% of disability-adjusted life-years.

 

The American College of Emergency Physicians just published a methodological rigorous clinical policy entitled “Critical Issues in the Diagnosis and Management of the Adult Psychiatric Patient in the Emergency Department.”

 

One question they sought to answer was “In the alert adult patient presenting to the ED with acute psychiatric symptoms, should routine laboratory tests be used to identify contributory medical conditions (nonpsychiatric disorders)?”

 

Their assessment was: “Do not routinely order laboratory testing on patients with acute psychiatric symptoms. Use medical history, previous psychiatric diagnoses, and physician examination to guide testing.” This was a Level C recommendation, based upon the quality of the research.

 

Bottom Line: Current literature does not support routinely ordering laboratory testing on patients with acute psychiatric symptoms. However, the quality of the evidence was not strong and local clinical context should be considered.

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Title: APRV Effects on RV Function

Category: Critical Care

Keywords: RV dysfunction, APRV, echo, ultrasound (PubMed Search)

Posted: 8/1/2017 by Daniel Haase, MD
Click here to contact Daniel Haase, MD

--RV systolic function is negatively affected by high RV afterload

--High mean airway pressures on the ventilator (particularly in modes such as APRV [airway pressure release ventilation]) can induce RV dysfunction

*****CLICK BELOW FOR A GREAT CASE!!!*****

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The answer appears to be ... it depends.

Early Oseltamivir Treatment in Influenza in Children1-3 Years of Age: A Randomized Controlled Trial

A study in 2010 out of Finland by Heinonen, et al showed that if given in the first 12 hours of symptom onset to otherwise healthy pediatric patients between the age of 1-3 years:

-  decrease incidence of acute otitis media by 85%

-  no difference if given within 24 hours

Among children with influenza A, oseltamivir started within 24 hours of symptom onset

-  shortened medium time to resolution of illness by 3.5 days (3.0 versus 6.5) in all children

- shortened median time to resolution of illness by 4.0 days in UNvaccinated children

- Reduced parental work absenteeism by 3 days

*  no differences were seen in children with influenza B *

Limitations***

- Single Center study in Finland

- The authors received support from the drug manufacturer

- The sample size of children with confirmed influenza cases with small (influenza A: 79, influenza B: 19)

Takeaway:

If you have a patient between the age of 1-3 years with very early symptoms concerning for flu, a positive rapid influenza A test could allow you to cut her symptoms by 3 days, prevent complications, and allow parents to go back to work sooner.

 

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Title: Importance of hemodialysis in intubated salicylate poisoned patients

Category: Toxicology

Keywords: salicylate poisoning, endotracheal intubation, hemodialysis (PubMed Search)

Posted: 7/27/2017 by Hong Kim, MD
Click here to contact Hong Kim, MD

Patients with severe salicylate poisoning may require endotracheal intubation due to fatigue from hyperventilation or mental status change.

A previously published study (Stolbach et al. 2008) showed that mechanical ventilation increases the risk of acidemia and clinical deterioration.

A small retrospective study investigated the impact of hemodialysis (HD) in intubated patients with salicylate poisoning.

 

Findings:

53 cases with overall survival rate of 73.2%

In patients with salicylate level > 50 mg/dL

  • No HD: 56% survival (14/25)
  • HD: 83.9% survival (0/9)

If salicylate level > 80 mg/dL

  • No HD: 0% survival (26/31)
  • HD: 83.3% survival (15/18)

Bottom Line:

There is moratality benefit of HD in intubated salicylate-poisoned patient.

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Improving Resuscitation Performance

  • Resuscitating the critically ill patient can often be quite stressful.
  • Stress has been shown to decrease the quality and effectiveness of decisions, decrease the amount of information a person can process, and lead to short-term memory deficits.
  • Recently, there has been emphasis on the use of performance-enhancing psychological skills (PEPS) to allow providers to think clearly, maintain situational awareness, recall important information, and perform skills efficiently.
  • A recent article highlights 4 key elements of an EM model for PEPS that can be used to improve performance in resuscitations.
    • Breathe - consider tactical breathing
    • Talk - positive instructional or motivational self-talk
    • See - visualize the steps of a procedure before actually performing it
    • Focus - use a trigger word as a prompt to shift attention to a prioritized task

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PCL injuries can sometimes have involvement of the posterolateral corner (PLC)

The dial test can be used to diagnose posterior lateral instability and help differentiate it from isolated PCL injuries

The dial test involves comparing the amount of external rotation of the lower leg at the knee while the knees are in 30° and in 90° of knee flexion.

https://www.youtube.com/watch?v=rnk62Y-nDSQ

An isolated injury to the posterolateral corner will result in more than 10° of external rotation in the injured knee that is present at 30° but not at 90° of knee flexion.

http://www.kneejointsurgery.com/wp-content/uploads/2015/06/DIAL-TEST.jpg

http://www.kneejointsurgery.com/wp-content/uploads/2015/06/DIAL-TEST-90.jpg

 

 

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Title: Reducing radiation exposure in evaluation of ventricular shunt malfunctions in children

Category: Pediatrics

Keywords: CT scans, radiation exposure, pediatrics (PubMed Search)

Posted: 7/21/2017 by Jenny Guyther, MD (Updated: 11/27/2024)
Click here to contact Jenny Guyther, MD

Ventricular shunt (VP) malfunction can be severe and life-threatening and evaluation has typically included a dry CT brain and a shunt series which includes multiple x-rays of the skull, neck, chest and abdomen.  The goal of this study was to decrease the amount of radiation used in the evaluation of these patients since these patients will likely present many times over their lifetime.  Several institutions have more towards a rapid cranial MRI, however, this modality may not be readily available.

This multidisciplinary team decreased the CT scan radiation dose from 250mA (the reference mA in the pediatric protocol at this institution) to 150 mA which allows for a balance between reducing radiation exposure and adequate visualization of the ventricular system.  They also added single view chest and abdominal x-rays.

The authors found that after implementing this new protocol, there was a reduction in CT radiation doses and number of x-rays ordered with no change in the return rate.

 

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Title: Vaginal Detox?

Category: Toxicology

Keywords: Vaginal pearls, intravaginal foreign bodies (PubMed Search)

Posted: 7/20/2017 by Kathy Prybys, MD (Updated: 7/21/2017)
Click here to contact Kathy Prybys, MD

Vaginal douching is a common and potentially dangerous practice. Women engage in this practice predominately for personal hygiene reasons but also with the false belief it will prevent or treat infections and for contraception. Numerous public health agencies and medical societies discourage douching as it has been associated with many adverse outcomes including pelvic inflammatory disease, bacterial vaginosis, cervical cancer, low birth weight, preterm birth, human immunodeficiency virus transmission, sexually transmitted diseases, ectopic pregnancy, recurrent vulvovaginal candidiasis, and infertility.

An increasing fad is the use of intravaginal detox products. Claiming to enhance female health by removing toxins, these mesh cloth-covered balls containing herbs such as mothersworth, osthol, angelica, borneol, and rhizoma, not FDA-approved, are inserted into the vagina for 3 days. Clinical experience demonstrates these products decompose into numerous pieces which become scattered retained intravaginal foreign bodies, cause mucosal irritation, and thereotically could serve as a nidus for serious infections.

 

 

 

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