UMEM Educational Pearls

Title: Sugar for sulfonylurea-induced hypoglycemia? Try octreotide.

Category: Toxicology

Keywords: sulfonylurea, hypoglycemia, octreotide (PubMed Search)

Posted: 7/28/2015 by Hong Kim, MD (Updated: 11/13/2024)
Click here to contact Hong Kim, MD

Oral hypoglycemic agents (e.g. sulfonylureas) can cause symptomatic hypoglycemia. Unlike metformin, sulfonylureas stimulate the release of insulin from beta-cells (in pancreas) in response to serum glucose level.

 

ED management of hypoglycemia involves:

  1. Dextrose (D50 50mL via IV) administration if symptomatic: e.g. altered mental status
  2. Feeding: food items that are more substantial than juice: e.g. food tray or sandwich
  3. Serial finger stick glucose check

 

However, for recurrent hypoglycemia (> 3 episodes of hypoglycemia), think about octreotide, rather than starting a dextrose (D5) infusion.

 

For example, D5 infusion at 150 mL/hour has only 7.5 gm of dextrose (calculation: D5% = 5gm/100 mL). One gram of dextrose contains about 4 calories (equivalent to one piece of Skittles) So, with a D5 infusion at 150 mL/hour, you are giving your patients 8 pieces of Skittles per hour. A bottle of Snapple lemon ice tea (non-diet) has more calories (150 calories in 16 oz. or 473 mL)! 

 

Octreotide 50 mcg SQ (q6 hour) injection will decrease the insulin release from the beta-cell by blocking the voltage-gated Ca channel on the beta-cell.

 

All patient who received octreotide in the ED requires admission to the hospital for observation. Patients can be safely discharge from the hospital when finger stick glucose level remains normal for 24 hours after the last dose of octreotide.

 

Bottom line: In sulfonylrea-induced recurrent hypoglycemia, administer octreotide, rather than continuous infusion of dextrose (D5) solution.



Title: What are the major global killers?

Category: International EM

Keywords: Global burden of disease, international, non-communicable diseases, injuries (PubMed Search)

Posted: 7/29/2015 by Jon Mark Hirshon, PhD, MPH, MD
Click here to contact Jon Mark Hirshon, PhD, MPH, MD

Every wonder what are the major global killers? Per the World Health Organization, the following were the top 20 causes. 

Not unexpected, diseases primarily of the elderly, such ischemic heart disease, stroke and chronic obstructive pulmonary disease are on the top of the list.  However, there are others, such as road traffic injuries and HIV/AIDS that could impact anyone.

 

Top 20 Causes of Global Mortality, 2012
Rank Cause Deaths (000s) % deaths Deaths per 100,000 population
0 All Causes 55859 100.0 789.5
1 Ischaemic heart disease 7356 13.2 104.0
2 Stroke 6671 11.9 94.3
3 Chronic obstructive pulmonary disease 3104 5.6 43.9
4 Lower respiratory infections 3052 5.5 43.1
5 Trachea, bronchus, lung cancers 1600 2.9 22.6
6 HIV/AIDS 1534 2.8 21.7
7 Diarrhoeal diseases 1498 2.7 21.2
8 Diabetes mellitus 1497 2.7 21.2
9 Road injury 1255 2.3 17.7
10 Hypertensive heart disease 1141 2.0 16.1
11 Preterm birth complications 1135 2.0 16.0
12 Cirrhosis of the liver 1021 1.8 14.4
13 Tuberculosis 935 1.7 13.2
14 Kidney diseases 864 1.6 12.2
15 Self-harm 804 1.4 11.4
16 Birth asphyxia and birth trauma 744 1.3 10.5
17 Liver cancer 740 1.3 10.5
18 Stomach cancer 733 1.3 10.4
19 Colon and rectum cancers 724 1.3 10.2
20 Alzheimer's disease and other dementias 701 1.3 9.9

 

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It's July, that means new doctors are learning to do central-lines...here's a quick video with some quick pearls on how to do that. Enjoy!

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Title: Triquetral fractures

Category: Orthopedics

Keywords: x-ray, fracture, wrist (PubMed Search)

Posted: 7/26/2015 by Brian Corwell, MD
Click here to contact Brian Corwell, MD

Triquetral fractures are the 2nd most common carpal fractures (scaphoid).

Dorsal surface most commonly.

Usually occur from impingement from the ulnar styloid, shear injury or from ligamentous avulsion.

XR: best seen on the lateral projection

http://images.radiopaedia.org/images/902179/42b3487baf4fb66183c51cd982477d_big_gallery.jpg

Remember this injury/radiographic appearance the next time you see an avulsion fracture dorsal to the proximal row of carpal bones on the lateral film but are unsure of the donor site.



Post- streptococcal glomerulonephritis (PSGN) is an inflammatory reaction of the kidneys following infection with group A strep, and can occur sub clinically or have a severe presentation requiring admission, Nephrology consult, and careful management.

This diagnosis should be considered in any child between ages 2-12, or adults over 60, presenting with sudden unexplained hematuria or brown urine.  Patients may also present with generalized edema secondary to urinary protein loss, hypertension, and acute kidney injury.  Since kidney involvement usually trails the throat injection by 2-3 weeks or more, the patient and their family may not relate the two symptoms.  A previous or current diagnosis of strep throat is not necessary to consider a patient for PSGN, since they may test negative by throat culture at the time of urinary and renal symptoms

When considering this diagnosis, the EM physician should order the following lab tests:
- Urinalysis (for casts and protein)
- Creatinine
- ASO Titer (or full streptozyme assay of 5 tests including ASO)
- Complement C3, C4, C50

Treatment is primarily supportive, and many cases will be mild enough to discharge home with pediatrician or Nephrology follow up.  However, some cases may warrant admission for AKI, pulmonary edema, or cerebral edema.  Edema can be managed with sodium restriction and loop diuretics.  Hypertension can be managed with anti hypertension medications.

Renal biopsy can confirm the diagnosis with the presence of epithelial crescents in the glomeruli, but this is only necessary in severe cases where it is important to determine the etiology of the nephritis.
 

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Title: Why Don't We Give GPIs in Acute Ischemic Stroke?

Category: Neurology

Keywords: antiplatelet, stroke, MI, Eptifibatide (PubMed Search)

Posted: 7/22/2015 by Danya Khoujah, MBBS
Click here to contact Danya Khoujah, MBBS

Given the similarity in pathophysiology, pharmacologic treatments for ischemic stroke have been modeled after those for acute myocardial infarction, such as the use of antiplatelets and thrombolytic agents. Have you ever wondered, why don't we give glycoprotein IIb/IIIa inhibitors (GPIs) as well?
A Cochrane review answers this question; GPIs increase morbidity in acute ischemic stroke (in the form of intracranial hemorrhage), with no evidence of benefit (improvement in Rankin Scale).
The systematic review looked at randomized clinical trials of GPIs in patients with ischemic stroke of 6 hours or less, alone or in combination with thrombolytics.

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Title: Care of the Drowning Patient

Category: Critical Care

Keywords: drowning, critical care, swimming, swim, water (PubMed Search)

Posted: 7/21/2015 by Feras Khan, MD
Click here to contact Feras Khan, MD

Care of Drowning Patients in the ED

  • 500,000 worldwide deaths per year/10 per day in US on average
  • Main goal of resuscitation is to reverse hypoxemia: endotracheal intubation, mouth-to-mouth, BVM depending on setting
  • In water resuscitation can be considered (mouth-to-mouth only) while the patient is being actively rescued
  • CPR with Airway emphasis- five rescue breaths, 30 compressions, then 2 breaths/30 compressions until the airway can be secured
  • Turning the patient over and performing abdominal thrusts or back blows is not helpful
  • ARDSnet protocol is generally used when intubated
  • No steroids or prophylactic antibiotics are indicated
  • Consider trauma (CT head and C-spine precautions based on history/exam)
  • Warm up your patient as needed--assume hypothermia on presentation
  • Can consider therapeutic hypothermia after ROSC and when rewarmed---no clear benefit here

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Question

81 year-old man was mowing the lawn and then felt a sudden pop, then pain in his left arm. What's the diagnosis and what's this sign called?

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Opiates Causing Cardiac Toxicity

- Opiates are well known in their ability to cause sedation, euphoria, and respiratory depression, however are classically considered devoid of cardiac properties.

- Methadone a synthetic central-acting μ-opioid receptor agonist has been associated with dose-dependent QTc interval prolongation and torsade de pointes (TdP).

- Utilization of other less known drugs of abuse, specifically loperamide (peripherally acting μ-opioid receptor agonist) has been increasing in popularity.

- A surge in recent case reports has shown a potential causal association of loperamide with prolongation of the QTc interval and subsequent TdP.

- Toxic ingestion of loperamide leading to TdP has been successfully managed with standard TdP therapies (magnesium, isoproterenol, and pacing).

 

 

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Title: Compartment Syndrome - Making the diagnosis

Category: Orthopedics

Keywords: compartment syndrome, diagnosis (PubMed Search)

Posted: 7/18/2015 by Michael Bond, MD
Click here to contact Michael Bond, MD

Compartment Syndrome

Compartment syndrome is a diagnosis that needs to be made quickly in order to prevent long term muscle, nerve, and vascular compromise.

Two pieces of information are needed to determine if the patient has compartment syndrome.

  1. The patient's diastolic blood pressure (DBP) value
  2. The pressure value obtained from the compartment of concern (Compartment pressure)

Diastolic Pressure - Compartment pressure < 30 makes the diagnosis of compartment syndrome

So if a diastolic blood pressure is 80 and the compartment pressure is 40 the difference is 40 mmHg and the patient likely does not need a fasciotomy.  The diagnosis can only be 100% onfirmed by a trip to the OR so these values should still be discussed with your local orthopaedist.  When calling them just make sure you know both the DBP and the compartment pressure so that it can be interpreted correctly.



Previous pearls have focused on diagnosing appendicitis in children including the use of the pediatric appendicitis score and the Alvarado score. Many facilities have begun using focused ultrasound as the initial step in diagnosing appendicitis whilean aging to avoid radiation. The question remains what to do with an indeterminate ultrasound (when the appendix can not be visualized)? The retrospective study cited looked at combining a low Alvarado score (less the 5) with an indeterminate ultrasound and showed a negative predictive value of 99.6%. A total of 522 children were included in this study. 390 of these children had inconclusive ultrasounds. Only 1 patient with a low Alvarado score and inconclusive ultrasound has appendicits. Only children who had surgery or clinical follow up were included.

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Title: How did physostigmine get a bad rap?

Category: Toxicology

Keywords: physostigmine, anticholinergic toxicity, TCA overdose, asystole (PubMed Search)

Posted: 7/16/2015 by Hong Kim, MD (Updated: 11/13/2024)
Click here to contact Hong Kim, MD

Physostigmine is a cholinergic agent (acetylcholine esterase inhibitor) that can be used to reverse anticholinergic toxicity. Its use has been declining since the publication of several case reports of physostigmine induced cardiac arrest in tricyclic antidepressant (TCA) overdose.

 

The first case report (and often cited) was by Pental P. et al. (Ann Emerg Med 1980), who presented 2 cases (32 and 25 year old) of asystole after administration of physostigmine (2 mg) in severe TCA overdose. These two cases both had widened QRS interval (120, 240 msec) due to TCA poisoning. Bradycardia preceded the asystole.

 

The second case report (Shannon M Pediatr Emerg Care 1998) reported a 15 year-old girl with QRS widening (120 msec) received 2 mg of physostigmine and developed severe bradycardia and then asystole.

 

Another case series (Knudson K et al. BMJ 1984) of 41 patients with overdose of maprotiline showed that physostigmine administration was associated with higher incidence of seizures. No asystole was noted.

 

Today physostigmine is contraindicated in TCA poisoning. But if we think about it, physostigmine administration probably wasn’t a good idea in the first place. Correcting anticholinergic toxicity of TCA has limited benefit; mortality from TCA overdose is usually associated with cardiac toxicity (Na-channel blockade) and should be treated with NaHCO3 administration

 

Physostigmine still has a role in treating isolated anticholinergic toxicity  (e.g. diphenhydramine, benztropine, dimenhydrinate, scopolamine, jimson weed overdose). Prior to physostigmine administration:

 

  1. Get a screening EKG to demonstrate there is no evidence of Na-channel blockade. Even diphenhydramine can cause Na-channel blockade and seizures in severe OD.
  2. Have atropine at bedside. Physostigmine is a cholinergic agent. When given too much, your patient will develop cholinergic toxicity.
  3. Administer 0.5 mg IV over 3-5 min. repeat as needed (every 3-5 min) to max dose of 2.0 mg for clinical effect (improvement of mental status).

 

Bottom line: If you suspect isolated anticholinergic toxicity, think about physostigmine. Like any medication, risk and benefit of administration should be considered prior to administration. 

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Title: Tuberculosis: Testing and Treatment

Category: International EM

Keywords: Tuberculosis, infectious disease, drug resistance, treatment (PubMed Search)

Posted: 7/15/2015 by Jon Mark Hirshon, PhD, MPH, MD
Click here to contact Jon Mark Hirshon, PhD, MPH, MD

Tuberculosis (TB) remains a deadly scourge killing approximately 1.5 million each year (see Pearl from 7/2/2105). Recognition by astute clinicians in the emergency department is key, as there is no readily available rapid test.

 

Current testing options:

1) Tuberculin skin test (also known as the Mantoux tuberculin skin test).  A small amount of fluid (tuberculin purified protein derivative) is placed intradermally, usually in the left forearm. A positive test means the person was infected with TB.  (Alternatively, if they grew up outside the US, they could have been vaccinated with Bacillus Calmette–Guérin or BCG.) A positive test is determined by the size of the reaction, but this can vary depending on the patient’s immune status.

 

2) Two interferon-gamma release assays or IGRA blood tests are approved for TB.  While not readily available in all institutions, this is the preferred method for someone vaccinated with BCG.

 

Diagnosis of TB disease is based upon:

  • Medical history
  • Physical exam
  • A positive TB test
  • Chest radiograph
  • Other appropriate laboratory test (such as acid fast bacilli on sputum smear followed by culture)

 

Treatment:

TB treatment depends on the susceptibility of the organism and the immune status of the patient.  For a susceptible organism in a non-HIV patient, the first-line anti-TB agents regimens include

  • isoniazid (INH),
  • rifampin (RIF),
  • ethambutol (EMB), and
  • pyrazinamide (PZA).

 

Typical treatment has an initial phase of 2 months, followed by a choice of several options for the continuation phase of either 4 or 7 months. Further information can be found at the CDC website on tuberculosis

 

Bottom Line

As stated previously, in the emergency department, maintain a strong clinical awareness for tuberculosis for someone with night sweats, cough, chest pain, and intermittent fever lasting for 3 weeks or longer.  In particular, consider this diagnosis for someone from a low- or middle-income country or if he or she is HIV positive.

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Blood Pressure Management in Severe Preeclampsia

  • Severe preeclampsia (preeclampsia + at least one severe complication) accounts for almost 40% of deaths in obstetrical ICU admissions.
  • Systolic arterial hypertension is the most important predictor of morbidity in patients with severe preeclampsia.
  • First-line agents to reduce blood pressure in severe preeclampsia are nicardipine and labetalol.
  • Hydralazine is no longer recommended as first-line therapy.
  • Magnesium is used as an anticonvulsant and should not be considered an antihypertensive.

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Question

7 year-old male "jammed" 5th finger while playing basketball with pain and swelling over finger. What's the diagnosis?

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Title: Sports hernia

Category: Orthopedics

Keywords: Hernia, abdominal pain (PubMed Search)

Posted: 7/11/2015 by Brian Corwell, MD
Click here to contact Brian Corwell, MD

A sports hernia is a painful musculotendinous injury to the medial inguinal floor.

It is the result of repetitive eccentric overload to the abdominal wall stabilizers of the pelvis.

It is common in sports that require sudden changes of direction or intense twisting movements.

Despite the term "hernia" in the title, it is not a true hernia as there is no "herniation" of abdominal contents

http://www.ssorkc.com/wp-content/uploads/2014/09/publagia.gif

Figure description: The upward and oblique pull of the abdominal muscles on the pubis fights against the downward and lateral pull of the adductors on the inferior pubis. This imbalance of forces can lead to injury.

PE: Evaluation of other GU/GYN/other intra-abdominal pathology comes first.

Clinician may note tenderness of the pubic ramus and medial inguinal floor.

Pain is more severe with resisted hip adduction and with resisted sit-up.

Combining these maneuvers (resisted situp while adducting hips) recreates the pathophysiology described above and is a good exam maneuver.

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Title: Reversing Dabigatran with Idarucizumab

Category: Toxicology

Keywords: dabigatran, bleeding, idarucizumab, reversal (PubMed Search)

Posted: 7/6/2015 by Bryan Hayes, PharmD (Updated: 7/9/2015)
Click here to contact Bryan Hayes, PharmD

The New England Journal of Medicine and Lancet both published studies evaluating idarucizumab for reversal of dabigatran. It is a monoclonal antibody fragment that binds dabigatran with high affinity. Dr. Ryan Radecki summarizes the two articles on his EM Lit of Note blog.

Here are a few take home points from these early studies:

  1. Both studies were funded by Boehringer Ingelheim, who not suprisingly also markets dabigatran. Skepticism is always welcome when the same company makes the drug and the antidote.
  2. The Lancet study was conducted in healthy volunteers, while the NEJM study was conducted in patients needing reversal but lacked a control group.
  3. Idarucizumab seems to reverse laboratory markers of anticoagulation from dabigatran rapidly and completely, including dilute thrombin time and ecarin clotting time. Not all institutions have these assays available.
  4. The dose that seems to 'work' the best is 5 gm given IV (two-2.5 gm infusions given no more than 15 minutes apart).
  5. Median investigator-reported time to cessation of bleeding was 11.4 hours in the NEJM study.
  6. 21 of the 90 patients in the NEJM study had 'serious adverse effects' including thrombotic events.
  7. The acquisition cost of this medication will most assuredly be high if and when it is FDA-approved in the U.S.

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Title: Cerebrospinal Fluid (CSF) Shunts

Category: Neurology

Keywords: CSF shunts, VP shunt, VA shunt, LP shunt (PubMed Search)

Posted: 7/8/2015 by WanTsu Wendy Chang, MD
Click here to contact WanTsu Wendy Chang, MD

 

Cerebrospinal Fluid (CSF) Shunts

  • CSF shunts are used to manage hydrocephalus by diverting CSF from either the ventricles within the brain or the subarachnoid space around the spinal cord to another body region. (Figure 1)
  • Several types of CSF shunts exist; common types are:
    • Ventriculoperitoneal shunt
    • Ventriculoatrial shunt
    • Ventriculopleural shunt
    • Lumboperitoneal shunt
  • A CSF shunt consists of 3 parts:
    • An inflow catheter directly draining CSF.
    • A one-way valve mechanism regulating the amount of CSF drainage.
    • An outflow catheter directing CSF to the drainage site.
  • There are 2 types of valve mechanisms:
    • Fixed pressure valves regulate CSF drainage by a predetermined pressure threshold (i.e. low, medium, high).
    • Adjustable pressure valves can be non-invasively adjusted, via specially designed magnetic tools, to set the pressure threshold.
    • Some valves include a reservoir that can be used to test shunt function or to sample CSF for laboratory studies. (Figure 2)
  • Shunt-related complications include:
    • Shunt malfunction (disconnection, migration, breaks, obstruction)
    • Shunt infection / ventriculitis / meningitis
    • Over-drainage
  • A special consideration for adjustable pressure valves is precaution around magnetic devices.  If a patient is undergoing a MRI, it is recommended for the valve setting to be checked and adjusted afterwards if necessary.

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Attachments



Question

15 year-old female field hockey player presents with left shoulder pain. Besides fatigue over several weeks, she has no past medical history and there is nothing remarkable on physical exam. What's the diagnosis? 

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Title: Early Glargine Administration at Start of DKA Treatment

Category: Pharmacology & Therapeutics

Keywords: diabetic ketoacidosis, insulin, glargine, DKA (PubMed Search)

Posted: 6/29/2015 by Bryan Hayes, PharmD (Updated: 7/4/2015)
Click here to contact Bryan Hayes, PharmD

Transitioning Diabetic Ketoacidosis (DKA) patients off an insulin infusion can be challenging. If a long-acting insulin, such as glargine or levemir, is not administered at the correct time to provide extended coverage, patients can revert back into DKA.

Pilot Study

A prospective, randomized, controlled pilot study in 40 patients evaluated administration of glargine within 2 hours of insulin infusion initiation compared to waiting until the anion gap (AG) had closed.

What they did

  • All patients received IV insulin.
  • Experimental: Subcutaneous insulin glargine given within 2 hours of diagnosis.
  • Control: Patients subsequently transitioned to long-acting insulin upon closure of AG.

What they found

Mean time to closure of AG, mean hospital LOS, incidents of hypoglycemia, rates of ICU admission, and ICU LOS were all similar between the groups.

Application to Clinical Practice

Although just a pilot study (using a convenience sample), early glargine administration seemed to be absorbed adequately (based on time to AG closure) and was not associated with increased risk of hypoglycemia. If confirmed in a larger study, this technique could help optimize care of DKA patients in the ED by eliminating the often-mismanaged transition step later on.

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