Category: Toxicology
Keywords: loperamide, opioid alternative, cardiac toxicity (PubMed Search)
Posted: 6/15/2016 by Hong Kim, MD
(Updated: 11/27/2024)
Click here to contact Hong Kim, MD
Loperamide is a peripheral mu-opioid receptor agonist that is found in over the counter anti-diarrheal medication. Following the trend of opioid abuse epidemic, loperamide has been promoted on online drug-use forum as a treatment for opioid withdrawal and as a possible alternative to methadone. At the same time, recreational use of loperamide has been increasing as an opioid alternative. Unlike therapeutic use of loparamide (2 – 4 mg), loraparmide abusers take supratherapeutic doses (e.g. 50 – 100 mg) to penetrate the CNS to produce opioid effects.
In published case reports, loperamide caused cardiac Na channel blockade (similar to TCA and bupropion) and K channel blockade, resulting in EKG changes including QRS interval > 100 msec with terminal R wave in aVR and QTc prolongation, respectively. Loperamide associated death has also been reported (autopsy finding), although the exact cause of death was not determined.
It is unclear if administration of NaHCO3 can reverse the cardiac Na channel blockade as in TCA and bupropion as the clinical experiences have been limited.
Bottom line:
Category: Critical Care
Posted: 6/15/2016 by Mike Winters, MBA, MD
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Heat Stroke
Gaudio FG, Grissom CK. Cooling methods in heat stroke. J Emerg Med 2016; 50:607-16
Category: Orthopedics
Keywords: Concussion, headache (PubMed Search)
Posted: 6/11/2016 by Brian Corwell, MD
Click here to contact Brian Corwell, MD
Medication-overuse headache (MOH) is one of the most common chronic headache disorders
Worldwide prevalence of 1 2%
Characterized by chronic headache and overuse of different headache medications
Withdrawal of the overused medication is the treatment of choice
A 2014 study looked at adolescent patients treated in a headache clinic with chronic post traumatic headaches (concussion headaches)
77 had chronic post-traumatic headache of 3-12 months' duration
54 of 77 (70.1%) met criteria for probable medication-overuse headache.
After the OTC medicine was stopped 68.5% had resolution or improvement !!
Excessive use of analgesics postconcussion may contribute to chronic post-traumatic headaches in some adolescents.
Sometimes the advise of "just keep taking the motrin and it'll get better" isnt the answer
Heyer et al., 2014 Pediatric Neurology
Category: Toxicology
Keywords: ketamine, agitation, prehospital, haloperidol (PubMed Search)
Posted: 6/7/2016 by Bryan Hayes, PharmD
(Updated: 6/27/2016)
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Ketamine is gaining traction as a prehospital option for managing severe agitation or excited delirium syndrome. Previous reports have mostly been case series, but a new prospective study adds some important information that may help delineate ketamine's role in this setting. [1] The study and an accompanying commentary are both open access. [2]
What They Did
Open-label before-and-after prospective comparison of haloperidol (10 mg IM) versus ketamine (5 mg/kg IM) for the treatment of acute undifferentiated agitation.
What They Found
Appliation to Clinical Practice
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Category: Neurology
Keywords: MRA, MRV, non-contrast, contrast-enhanced, gadolinium, time-of-flight, TOF (PubMed Search)
Posted: 6/8/2016 by WanTsu Wendy Chang, MD
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Gadolinium - To Use or Not Use?
Non-Contrast MRA/MRV | Contrast-Enhanced MRA/MRV | |
How Does It Work? | * Time-of-flight (TOF) is a commonly used sequence * Relies on flow of blood into imaging plane * Difference between signal of blood and suppressed background tissue | * Similar to CT angiography/venography * Higher intravascular signal purely from gadolinium-based contrast, not dependent on flow
|
Pros | * Does not require contrast
| * Generally better image quality * Shorter acquisition time |
Cons | * Slow, turbulent, or retrograde flow may result in signal loss * Over-estimates stenosis * Longer acquisition time | * RIsks associated with contrast use * Timing of image acquisition important |
Applications | * Patients with allergy to gadolinium, renal dysfunction, pregnancy * Evaluation of intracranial vessels and cerebral venous system | * Evaluation of stenoses and occlusions of the neck vessels and their origins at the aortic arch
|
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Category: Critical Care
Keywords: PPI, GI bleed, UGIB, GI hemorrhage (PubMed Search)
Posted: 6/7/2016 by Daniel Haase, MD
Click here to contact Daniel Haase, MD
1. Laine L, Jensen DM. Management of patients with ulcer bleeding. Am J Gastroenterol. 2012 Mar;107(3):345-60; quiz 361. doi: 10.1038/ajg.2011.480. Epub 2012 Feb 7. Review. PubMed PMID: 22310222.
2. Barkun AN, et al; International Consensus Upper Gastrointestinal Bleeding Conference Group. International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding. Ann Intern Med. 2010 Jan 19;152(2):101-13. doi: 10.7326/0003-4819-152-2-201001190-00009. PubMed PMID: 20083829.
3. Sachar H, Vaidya K, Laine L. Intermittent vs continuous proton pump inhibitor therapy for high-risk bleeding ulcers: a systematic review and meta-analysis. JAMA Intern Med. 2014 Nov;174(11):1755-62. doi: 10.1001/jamainternmed.2014.4056. Review. PubMed PMID: 25201154; PubMed Central PMCID: PMC4415726.
4. Neumann I, et aI. Comparison of different regimens of proton pump inhibitors for acute peptic ulcer bleeding. Cochrane Database Syst Rev. 2013 Jun 12;(6):CD007999. doi: 10.1002/14651858.CD007999.pub2. Review. PubMed PMID: 23760821.
5. Pantoprazole. Micromedex 2.0. Truven Health Analytics, Inc. Available at http://micromedexsoultsions. Accessed June 7, 2016.
Category: Pharmacology & Therapeutics
Keywords: clindamycin, trimethoprim-sulfamethoxazole, wound infection, TMP-SMX (PubMed Search)
Posted: 6/2/2016 by Bryan Hayes, PharmD
(Updated: 6/4/2016)
Click here to contact Bryan Hayes, PharmD
In settings where community-acquired MRSA is prevalent, which antibiotic is best for uncomplicated wound infections?
New Study
What They Found
Application to Clinical Practice
Talan DA, et al. A randomized trial of clindamycin versus trimethoprim-sulfamethoxazole for uncomplicated wound infection. Clin Infect Dis 2016;62(12):1505-13. [PMID 27025829]
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Category: Toxicology
Keywords: Bupropion, Seizure, Cardivascular instability (PubMed Search)
Posted: 6/2/2016 by Kathy Prybys, MD
(Updated: 6/3/2016)
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Bupropion (Wellbutrin, Zyban) is one of the most frequently prescribed antidepressants and smoking cessation agents. A lesser incidence of undesirable side effects such as weight gain and sexual dysfunction when compared to other antidepressants lends to its popularity. Bupropion's mechanism of action is only partially understood but it is known to be a norepinephine dopamine reuptake inhibitor and anticholinergic receptor blocker at certain nicotinic receptors. Bupropion has a monocyclic structure similar to amphetamines. Seizures are a major concern in overdose. When first released, Bupropion was initially withdrawn from the market due to its narrow therapeutic window with seizures occurring at doses as low as 450 mg.
Life threatening Bupropion ingestion, Is there a role for intravenous fat emulsion? Livshits Z, Feng L, et al. Basic & Clinical Toxicology & Pharmacology, 2011, 109. 418-22.
Incidence and onset of delayed seizures after overdoses of extended release Bupropion. Starr P, Klein-Schwartw W, et al. Am Journal EM, 2009 Oct(27)8: 911-15.
Category: International EM
Keywords: travel, infectious diseases, CDC (PubMed Search)
Posted: 6/1/2016 by Jon Mark Hirshon, PhD, MPH, MD
(Updated: 11/27/2024)
Click here to contact Jon Mark Hirshon, PhD, MPH, MD
As we head into the summer travel season, it is important to know what potential dangers lurk out there for the unwary traveler. While injuries are usually the primary cause for death and disability for Americans abroad, what about other diseases?
The Centers for Disease Control and Prevention (CDC) has a webpage with travel health notices.
They are three types of notices:
Currently, there are a number of Level 1 watches and Level 2 alerts for different countries, but no Level 3 warnings. Many of the Level 2 alerts relate to Zika virus, but there are others for MERS, Yellow Fever and Polio.
To see more, go to: http://wwwnc.cdc.gov/travel/notices
Category: Critical Care
Posted: 5/31/2016 by Haney Mallemat, MD
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Follow me on Twitter (@criticalcarenow)a
Category: Orthopedics
Keywords: X-ray, radiographs (PubMed Search)
Posted: 5/4/2016 by Brian Corwell, MD
(Updated: 5/28/2016)
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Radiographs of the sacrum and coccyx in the emergency department (ED) have no quantifiable clinical impact, according to a study published in the American Journal of Roentgenology.
Researchers from Emory University Midtown Hospital and Morehouse School of Medicine in Atlanta, GA, sought to determine the yield and clinical impact of sacrum and coccyx radiographs performed in the ED.
Sacrum and coccyx X-rays performed on 687 consecutive patients over a six-year period in level-1 and level-2 trauma centers (4 total hospitals). The patients’ mean age was 48.1, 61.6% were women. The images were categorized as positive for acute fracture or dislocation, negative, or other.
The researchers then analyzed:
• Follow-up advanced imaging in the same ED visit
• Follow-up advanced imaging within 30 days
• New analgesic prescriptions
• Clinic follow-up
• Surgical intervention within 60 days
The researchers found positive results in 58 of the 687 patients, a positivity rate of 8.4%.
None of the 58 positive cases had surgical intervention.
There was no significant association between sacrum and coccyx radiograph positivity and analgesic prescription or clinical follow-up among the patients evaluated at the level-1 trauma centers.
However at the level-2 trauma centers, 34 (97.1%) of 35 patients with positive sacrum and coccyx radiographs received analgesic prescriptions or clinical referrals. Negative cases were at 82.9%.
Of all cases, 39 patients (5.7%) underwent advanced imaging in the same ED visit and 29 patients (4.3%) underwent imaging within 30 days.
“Sacrum and coccyx radiography results had no significant correlation with advanced imaging in the same ED visit,” the authors wrote. “There was no significant difference in 30-day advanced imaging at the level-1 trauma centers, but there was at the level-2 trauma centers.”
The researchers concluded that routine sacrum and coccyx radiography should not be part of ED practice and that patients should be treated conservatively based on clinical parameters.
Sacrum and Coccyx Radiographs Have Limited Clinical Impact in the Emergency Department.
Hanna et al. American Journal of Roentgenology Volume 206, Issue 4
Category: Neurology
Keywords: headache, analgesia, cluster, migraine, oxygen (PubMed Search)
Posted: 5/25/2016 by Danya Khoujah, MBBS
Click here to contact Danya Khoujah, MBBS
Short Answer: No
Classically, some therapies for headaches are thought to be effective in only certain classifications of headaches, such as triptans in migraines, or oxygen in cluster headaches. This is not necessarily true.
Triptans have been successfully used in cluster headaches, as found in the 2013 Cochrane review.1
More recently, "high-flow" oxygen (referring to 12 L/min of oxygen, delivered through a facemask) has been studied in migraine headaches, with promising results. When compared with placebo (air), oxygen used for 15 minutes was more effective in pain relief and improving visual symptom, with no significant adverse events. 2
1. Law S, Derry S, Moore RA. Triptans for acute cluster headache. Cochrane Database Syst Rev. 2013 Jul 17;7
2. Singhal AB, Maas MB, Goldstein JN, et al. High-flow oxygen therapy for treatment of acute migraine: A randomized crossover trial. Cephalalgia. 2016 May 20.
Category: Critical Care
Keywords: ATS, non invasive ventilation, aspirin, nighttime extubation, dialysis (PubMed Search)
Posted: 5/24/2016 by Feras Khan, MD
(Updated: 11/27/2024)
Click here to contact Feras Khan, MD
American Thoracic Society (ATS) Conference Highlights
The ATS conference was last week in San Francisco and a few cool articles were presented. They are briefly summarized below:
1. Using a helmet vs face mask for ARDS: Non-invasive ventilation is not ideal for ARDS for a variety of reasons. At the same time, endotracheal intubation and ventilation carries some risks as well. Could a new design of a "helmet" device make a difference? This one center study from the Univ of Chicago suggests that it would: decreased rate of intubation, increase in ventilator free days, and decrease in 90 day mortality. http://jama.jamanetwork.com/article.aspx?articleid=2522693
2. Can aspirin prevent the development of ARDS in at risk patients in the emergency department? Unfortunately, it does not appear to help. http://jama.jamanetwork.com/article.aspx?articleid=2522739
3. Should you start renal-replacement therapy (HD, CRRT etc) in critically ill patients with AKI sooner or later? Seems to have no difference and may actually lead to patients not needing any dialysis. Really a great read if you have time. http://www.nejm.org/doi/full/10.1056/NEJMoa1603017?query=OF&
4. Should I extubate at night? Lastly, probably don’t extubate at night if you can avoid it. Or just be cautious. http://www.atsjournals.org/doi/abs/10.1164/ajrccmconference.2016.193.1_MeetingAbstracts.A6150
Category: Pediatrics
Keywords: Apparent life threatening event, ALTE, apnea, low risk infants, brief unexplained resolved events (PubMed Search)
Posted: 5/20/2016 by Jenny Guyther, MD
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The American Academy of Pediatrics has developed a new set of clinical practice guidelines to help better manage and think about patients who have experienced an ALTE (Apparent Life Threatening Event). The term BRUE (Brief Resolved Unexplained Event) will replace ALTE.
BRUE is defined as an event in a child younger than 1 year where the observer reports a sudden, brief and now resolved episode of one or more of: cyanosis or pallor; absent, decreased or irregular breathing, marked change in tone or altered level of responsiveness. A BRUE can be diagnosed after a history and physical exam that reveal no explanation.
BRUE can be classified as low risk or high risk. Those that can be categorized as low risk do not require the extensive inpatient evaluation that has often occurred with ALTE.
LOW risk BRUE:
Age > 60 days
Gestational age at least 32 weeks and postconceptual age of at least 45 weeks
First BRUE
Duration < 1 minute
No CPR required by a trained medical provider
No concerning historical features (outlined in the article)
No concerning physical exam findings (outlined in the article)
Recommendations for low risk BRUE:
-SHOULD: Educate, shared decision making, ensure follow up and offer resources for CPR training
-May: Obtain pertussis and 12 lead; briefly monitor patients with continuous pulse oximetry and serial observations
-SHOULD NOT: Obtain WBC, blood culture, CSF studies, BMP, ammonia, blood gas, amino acids, acylcarnitine, CXR, echocardiogram, EEG, initiate home cardiorespiratory monitoring, prescribe acid suppression or anti-epileptic drugs
-NEED NOT: obtain viral respiratory tests, urinalysis, glucose, serum bicarbonate, hemoglobin or neuroimaging, admit to the hospital solely for cardiorespiratory monitoring
*When looking at the evidence strength behind these recommendations, the only one that had a strong level was that you should not obtain WBC, blood culture or CSF
Tieder JS, Bonkowsky JL, Etzel RA, et al. Brief Resolved Unexplained Events (Formerly Apparent Life-Threatening Events) and Evaluation of Lower-Risk Infants. Clinical Practice Guideline. Pediatrics. 2016; 137 (5):e20160590.
Category: International EM
Keywords: Blast, Bombings, Explosions, Terrorism (PubMed Search)
Posted: 5/4/2016 by Jon Mark Hirshon, PhD, MPH, MD
(Updated: 5/18/2016)
Click here to contact Jon Mark Hirshon, PhD, MPH, MD
The classification of blast injuries was first described by Zuckerman in 1941 and is still widely used today. This system organizes injuries by the mechanism through which they are sustained and classifies them as primary, secondary, tertiary and quaternary. These injuries may occur in isolation or in combination with each other.
Category | Mechanism | Typical Injuries |
Primary | Caused by blast wave of overpressure | Tympanic membrane rupture, blast lung, intestinal hemorrhage and rupture |
Secondary | Caused by flying debris and shrapnel | Blunt and penetrating traumatic injuries
|
Tertiary | Due to individual being thrown by blast | Blunt and penetrating traumatic injuries
|
Quaternary | Thermal, toxic, and asphyxiant effects | Thermal burns, chemical burns, exposure to toxins, asphyxiation
|
The term quinary blast injury has also been used to describe delayed effects of explosions, such as infections, radiation exposure, and other toxic exposures.
Author: R. Gentry Wilkerson
Category: Critical Care
Posted: 5/17/2016 by Mike Winters, MBA, MD
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Situations Where ECMO Will Likely Fail
Schmidt M, et al. Ten situations in which ECMO is unlikely to be successful. Intensive Care Med 2016; 42:750-752.
Category: Orthopedics
Keywords: MI, Sport (PubMed Search)
Posted: 5/14/2016 by Brian Corwell, MD
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https://www.youtube.com/watch?v=sCFOObsx_W4
What is their risk of MI???
Anger outbursts are bad for your heart. Out of 300 patients with an acute MI, just over 2% reported losing their temper within 2 hours of the event. A review of nine studies of rage and cardiovascular events all found an increase in cardiovascular events in the 2 hours preceding an anger outburst. Examples included arguments at home, at work or by road rage. Compared with their usual anger levels, the relative risk of heart attack from a fit of rage was 8.5.
What about those of us who are just fanatics, I mean fans....A recent study of World Cup soccer found that the intense strain and excitement of viewing a dramatic soccer match more than doubles the risk of acute heart attack, particularly in men with known coronary heart disease. This was regardless of the outcome of the match!
Eichner, E. Randy. Current Sports Medicine Reports: March/April 2016
Category: Toxicology
Keywords: digoxin, chronic, poisoning, immune Fab (PubMed Search)
Posted: 5/9/2016 by Bryan Hayes, PharmD
(Updated: 5/12/2016)
Click here to contact Bryan Hayes, PharmD
Patients with chronic digoxin toxicity generally have multiple co-morbidities such as renal failure, dehydration, and cardiac failure. Sick patients with chronically high digoxin levels may have more than just digoxin toxicity as the cause of illness.
A New Study
Prospective observational study with the primary objective to investigate changes in free digoxin concentrations and clinical effects on heart rate and potassium concentrations in chronic digoxin poisoning when digoxin immune Fab are given.
What They Found
One to two vials of digoxin immune Fab initially bound all free digoxin confirming Fab efficacy. However, this was associated with only a moderate improvement in HR (49 to 57 bpm) and potassium (5.3 to 5.0 mmol/L).
Application to Clinical Practice
Chan BS, et al. Efficacy and effectiveness of anti-digoxin antibodies in chronic digoxin poisonings from the DORA study (ATOM-1). Clin Toxicol. 2016 Apr 27. Epub ahead of print. [PMID 27118413]
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Category: Neurology
Keywords: magnetic resonance imaging, MRI, T1, T2, FLAIR, DWI, ADC (PubMed Search)
Posted: 5/11/2016 by WanTsu Wendy Chang, MD
Click here to contact WanTsu Wendy Chang, MD
Want to learn more about how to read a brain MRI? Here are the basics:
Stay tuned for more pearls in this series on brain MRI!
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Category: Critical Care
Keywords: Zika, Guillain-Barre, GBS, ITP, Critical Care (PubMed Search)
Posted: 5/10/2016 by Daniel Haase, MD
Click here to contact Daniel Haase, MD
Zika virus has received significant media attention in the US due to its recent link with teratogenicity. But Zika is also associated with critical and life-threatening complications, including death. Differentiating it from other Flavivirus diseases such as Dengue or Chikungunya can be challenging.
Diagnosis
Complications
1. Petersen LR, Jamieson DJ, Powers AM, Honein MA. Zika Virus. N Engl J Med. 2016 Apr 21;374(16):1552-63. doi: 10.1056/NEJMra1602113. Epub 2016 Mar 30. Review. PubMed PMID: 27028561.
2. LaBeaud, AD. Zika virus infection: An overview. uptodate.com. Accessed 5/10/2016.
3. Cao-Lormeau VM, et al. Guillain-Barr Syndrome outbreak associated with Zika virus infection in French Polynesia: a case-control study. Lancet. 2016 Apr 9;387(10027):1531-9. doi: 10.1016/S0140-6736(16)00562-6. Epub 2016 Mar 2. PubMed PMID: 26948433.
4. Centers for Disease Control and Prevention. Zika virus - What clinicians need to know? Clinician Outreach and Communication Activity (COCA) Call, January 26, 2016. Available at: http://emergency.cdc.gov/coca/ppt/2016/01_26_16_zika.pdf. Accessed May 10, 2016.