UMEM Educational Pearls

Title: Bactrim + ACE-Inhibitor/ARB + Older Adult = Increased Sudden Death

Category: Toxicology

Keywords: Bactrim, trimethoprim-sulfamethoxazole, ACE-inhibitor, angiotensin receptor blocker, ARB (PubMed Search)

Posted: 11/5/2014 by Bryan Hayes, PharmD (Updated: 11/13/2014)
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A new population-based case-control study in older adults has linked the administration of trimethoprim-sulfamethoxazole (Bactrim, TMP-SMX) to increased risk of sudden death in patients also receiving angiotensin converting enzyme inhibitors (ACE-I) or angiotensin receptor blockers (ARB). [1]

Hyperkalemia is the suspected cause. [2] Compared to amoxicillin, TMP-SMX was associated with an increased risk of sudden death (adjusted odds ratio 1.38, 95% confidence interval 1.09 to 1.76) within 7 days of exposure to the antibiotic.

Practice Change

In older patients receiving ACE-Is or ARBs, TMP-SMX is associated with an increased risk of sudden death. When appropriate, alternative antibiotics should be considered.

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Title: Evaluation of anisocoria

Category: Neurology

Keywords: anisocoria, Horner syndrome, third nerve palsy, tonic pupil (PubMed Search)

Posted: 11/12/2014 by WanTsu Wendy Chang, MD
Click here to contact WanTsu Wendy Chang, MD

 

Anisocoria, or unequal pupil sizes, is a common condition.  Approximately 20% of the normal population have physiologic anisocoria.  However, pathologic anisocoria indicates disease of the iris, parasympathetic pathway or sympathetic pathway.  A systematic approach to the evaluation of anisocoria can help differentiate between etiologies that range from benign to life threatening.

 

The most important question in the evaluation of anisocoria is whether both pupils are normally reactive to light or is one (or both) poorly reactive.  If both pupils are reactive, the smaller pupil is abnormal and the lesion is likely in the sympathetic pathway because pupillary constriction (parasympathetic pathway) is intact.  If one pupil is poorly or non-reactive (and there is no relative afferent pupillary defect), the larger pupil is abnormal and the lesion is likely in the parasympathetic pathway.

 

 

DDx of anisocoria with normally reactive pupils:

  • Physiologic anisocoria
  • Horner syndrome

DDx of anisocoria with poorly or non-reactive pupil:

  • Iris sphincter damage (traumatic mydriasis)
  • Pharmacologic blockade
  • Tonic pupil
  • Cranial nerve III palsy

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Aminoglycosides in Critically Ill Patients

  • Aminoglycosides remain an important class of antibiotics in critically ill patients, especially those infected with multidrug-resistant organisms (i.e., Klebsiella  and Pseudomonas spp.).
  • Importantly, aminoglycosides are concentration-dependent antibiotics and a greatly affected by the increased volume of distribution and altered elimination commonly seen in the critically ill.
  • As a result, recommended doses are often too low to be effective. 
  • Initial doses of aminoglycosides should, therefore, be higher in critically ill patients.
    • Amikacin: 25-30 mg/kg
    • Gentamicin: 7-9 mg/kg
    • Tobramycin: 7-9 mg/kg
  • Subsequent doses are based on drug level monitoring.

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Question

Parasternal long-axis of two different patients. What is the:

  1. structure labeled “A”
  2. structure labeled “B”
  3. diagnosis on the left?
  4. diagnosis on the right?

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Coronary Subclavian Steal Syndrome

Coronary subclavian steal syndrome (CSSS) is defined as coronary ischemia resulting from the reversal of flow in an internal mammary arterial graft usually secondary to subclavian stenosis.

Angiographic subclavian stenosis is defined as greater than 50% narrowing or greater than 20mmHg pressure difference across a lesion.

CSSS occurs in up to 4.5% of patients with prior CABG & common in older individuals with existing peripheral vascular disease.

CSSS most commonly manifests as stable angina, but frequently presents as unstable angina, acute myocardial infarction, acute systolic heart failure or even cardiogenic shock.

Screening for subclavian stenosis prior to CABG w/bilateral noninvasive blood pressure assessment, and a 15 mmHg or greater discordance should elicit further imaging.

Percutaneous revascularization is the first-line therapy for CSSS and has excellent long-term outcomes. 

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Title: knee dislocation

Category: Orthopedics

Keywords: trauma, knee, dislocation (PubMed Search)

Posted: 11/8/2014 by Brian Corwell, MD
Click here to contact Brian Corwell, MD

Beware of spontaneous reduction masking the true injury!

Knee dislocations are rare due to supporting ligaments (MVCs, falls, sports)

but can be seen after minor trauma in obese patients.

Named by the direction of the displacement of the tibia relative to the femur

- Anterior and posterior are most common

Dislocations involve disruption of at least 2 of the major knee ligaments (ACL/PCL most common)

Usually associated with large hemarthrosis however capsular tearing may allow dissipation of the blood into adjacent soft tissue.

Consider a spontaneously reduced knee dislocation in those with a significant mechanism of injury in the setting of multidirectional instability,



Emergency Physician Bedside Ultrasound for Appendicitis

Why?

To reduce length of stay, improve patient care, and reduce radiation exposure in young patients.

How?

Start with pain medication so you get a better study. (Consider intranasal fentanyl for quicker pain relief and diagnostics in pediatrics.) Study results are also improved with a slim body habitus.

Place the patient supine

Use a high-frequency linear array transducer

Start at the point of maximal tenderness in the RLQ

Transverse and longitudinal planes "graded compression" to displace overlying bowel gas which usually has peristalsis (See Sivitz, et al article for images of "graded compression")

Appendix is usually anterior to the psoas muscle and iliac vein and artery as landmarks

Measure from outer wall to outer wall at the most inflamed portion of the appendix (usually distal end)

Example:

Positive study:

A non-compressible, blind-ending tubular structure in the longitudinal axis >6 mm without peristalsis (see second image above with 8.3 mm diameter measurement)

A target sign in the transverse view (see first image above)

Additional suggestive findings: appendiceal wall hyperemia with color Doppler, appendicoliths hyperechoic (white) foci with an anechoic (black) shadow, periappendiceal inflammation or free fluid

Negative study:

Non-visualization of the appendix with adequate graded compression exam in the absence of free fluid or inflammation.

Limitations for visualization and possible false negative result:

Retrocecal appendix and perforated appendix are difficult to visualize with US.

Pitfalls:

US has good specificity (93% in Sivitz et al article), but limited sensitivity (85% in Sivitz et al article), so trust your clinical judgement. You may need a MRI (pregnant/pediatrics) or CT as they have improved, but not perfect sensitivity.

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Title: Lily of the Valley, Part 2

Category: Toxicology

Keywords: Digoxin, Cardioactive Steroids, Digitoxin, Digoxin-specific Fab Fragments (PubMed Search)

Posted: 11/7/2014 by Kishan Kapadia, DO
Click here to contact Kishan Kapadia, DO

Digoxin-specific antibodies are produced in immunized sheep and have high binding affinity for digoxin and, to a lesser extent, digitoxin and other cardiac glycosides. The Fab fragment binds free digoxin and once the digoxin-Fab complex is formed, the digoxin molecule is no longer pharmacologically active.  The complex is renally eliminated and has a half-life of 14-20 hours (may increase 10-fold with renal impairment).  Reversal of signs of digoxin/digitalis intoxication usually occurs within 30-60 minutes, with complete reversal varying up to 24 hours.

Contraindication: None known.  Caution is warranted in patients with known sensitivity ot ovine (sheep) products.  Product may contain traces of papain and caution advised in patients with allergies to papain, papaya extracts, chymopapain.

Adverse effects

1) Monitor for potential hypersensitivity reactions and serum sickness

2) In patients with renal insufficiency and impaired renal clearance of dig-Fab complex, a delayed rebound of free serum digoxin levels may occur

3) Removal of the effect of digoxin/digitalis may exacerbate preexisting heart failure

4) Removal of digoxin/digitalis effect may cause hypokalemia

Laboratory interaction: Digoxin-Fab complex cross-reacts with the antibody commonly utilized in quantitative immunoassay techniques.  This results in falsely high serum concentrations of digoxin due to measurement of the inactive Fab complex.  Therefore, measure free digoxin levels, which may be useful for patients with renal impairment.

Dosing: Each vial of Fab product binds 0.5 mg of digoxin.

Digoxin-specific Fab (round up vial calculation)

# of vials = Digoxin concentration (ng/mL) x Pt Wt (kg)

                                               100



Title: Killer Bioterrorism Agents & Diseases: Category A

Category: International EM

Keywords: Bioterrorism, anthrax, botulism, plague, smallpox, tularemia, viral hemmorrhagic fevers (PubMed Search)

Posted: 11/5/2014 by Jon Mark Hirshon, PhD, MPH, MD
Click here to contact Jon Mark Hirshon, PhD, MPH, MD

Background: The Centers for Disease Control and Prevention (CDC) classifies potential bioterrorism agents into three categories, with Category A the most deadly.

 

Category A: These are the highest priority agents/diseases because they:

  • can be easily disseminated or transmitted from person to person;
  • result in high mortality rates and have the potential for major public health impact;
  • might cause public panic and social disruption; and
  • require special action for public health preparedness.

 

Specific Category A Agents/Diseases:

  • Anthrax (Bacillus anthracis)
  • Botulism (Clostridium botulinum toxin)
  • Plague (Yersinia pestis)
  • Smallpox (variola major)
  • Tularemia (Francisella tularensis)
  • Viral hemorrhagic fevers (including filoviruses such as Ebola and Marburg, as well as arenaviruses such as Lassa)

 

Bottom Line: With the exception of smallpox, these disease still occur in various parts of the globe including the United States. As can be seen by the current Ebola epidemic in West Africa, the U.S. public health system and healthcare providers must be prepared to recognize and treat these agents.

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Question

A patient presents post-motor vehicle crash with chest pain and dyspnea. The lung ultrasound is shown below. What's the diagnosis?

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Title: Back 2 Basics Series: Your Simple RSI Checklist - SOAP ME

Category: Critical Care

Keywords: Airway, critical care, RSI, rapid sequence intubation (PubMed Search)

Posted: 11/3/2014 by John Greenwood, MD (Updated: 11/4/2014)
Click here to contact John Greenwood, MD

Back 2 Basics Series: Your Simple RSI Checklist - SOAP ME

The use of a checklist during high stress medical procedures is often recommended.  Rapid sequence intubation (RSI) is a classic situation where having a checklist can ensure adequate preparation however, if you don’t have a checklist – this simple mnemonic will make sure you are well prepared for a successful intubation.

 

Mnemonic – “SOAP ME”  
Suction
  • Yankauer suction placed under the mattress on the right side, head of bed (x2 if GI bleed, vomiting, or lots of secretions)
Oxygen
  • Bag valve mask (with PEEP valve) ready
  • Non-rebreather mask on patient (O2 wide open)
  • Nasal cannula on the patient (with 15L O2) during RSI
Airways
  • Oral, nasal airways
  • 2 ETT (expected size & one size below) w/ balloons checked, & stylet straight to cuff
  • 1 ETT ready for video laryngoscopy (curved stylet needed)
  • Rescue devices (Laryngeal mask airway, scalpel, etc.)
Positioning
  • Ear-to-sternal notch position
  • Ramped if obese
Monitors & Meds
  • Continuous monitoring devices
  • RSI Meds: Drawn up in carefully considered doses, labeled syringes
    • Sedative (Ketamine, etomidate, etc.)
    • Paralytic (rocuronium, succinylcholine)
  • Post intubation sedation meds (Propofol, fentanyl, etc)

EtCO2 & other Equipment

  • Continuous EtCO2 or at least color-change device to confirm successful intubation
  • Bougie placed under the mattress next to yankauer suction
  • 2 laryngoscopes (MAC 3 & 4) with lights checked.
  • Video laryngoscope plugged in & turned on

 

The SOAP ME mnemonic is a quick and useful technique to remember only the basics of airway management and preparation.  Always remember to also assign roles to team members and communicate clearly to maximize your chances of success.  

 

References
  1. Dr. Richard Levitan
  2. Dr. Ken Butler

Follow me on Twitter @JohnGreenwoodMD

 



Heart Failure & Pulmonary Hypertension (Part II)

- HFpEF-PH management guidelines recommend the treatment of symptoms of congestion and volume overload, targeting LV relaxation and co-morbidities; including the management of pulmonary congestion, ischemia, sleep apnea, atrial fibrillation, and diabetes.

- Both atrial/ventricular dysrhythmias contribute to the mortality associated with HF & control of particularly atrial fibrillation, is an essential part of the early pulmonary vascular remodeling process.

- Both endothelin receptor antagonists (ERA) and prostanoids have been effective for PAH & clinical trials utilizing these agents have also been attempted in treatment of PH due to left heart disease, but have proven to be either neutral or even detrimental.

- Selective dilation of the pulmonary vessels in patients with postcapillary PH, without simultaneously ensuring the unloading of the LV, can cause profound pulmonary venous congestion resulting in sudden pulmonary edema, which greatly increases the morbidity in patients with this form of PH.

- Currently, the most compelling published data for pharmacological treatment targeting PH in HFpEF involves phosphodiesterase (PDE) inhibitor sildenafil.

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Title: Penicillin-Cephalosporin Cross-Reactivity Made Easy

Category: Pharmacology & Therapeutics

Keywords: penicillin, cephalosporin, allergy, cross-reactivity (PubMed Search)

Posted: 10/7/2014 by Bryan Hayes, PharmD (Updated: 11/4/2014)
Click here to contact Bryan Hayes, PharmD

The cross-reactivity between cephalosporins and penicillins is significantly lower than the 10% figure many of us learned. In fact, the beta-lactam ring is rarely involved. So, when the warning pops up next time you order ceftriaxone in a penicillin-allergic patient, what should you do?

In a patient with a documented penicillin allergy, here is a simple chart to help determine when a cephalosporin is ok to use:

  

Common penicillins and cephalosporins with similar side chains include ampicillin/amoxicillin and cephalexin, cefaclor, cephadroxil, and cefprozil.

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Background:

  • There is a great deal of fear, media attention, and misinformation concerning Ebola.  
  • As an emergency physician, you must be able to identify and appropriately manage individuals with possible Ebola presenting to your hospital. 
  • ACEP's Ebola Expert Panel worked with the Centers for Disease Control and Prevention to help create a clear and concise algorithm in case someone presents with possible Ebola.

ED Algorithm For Patients with Possible Ebola

  • Identify:
    • Do they have the right travel history (step 1)?
    • Do they have the right signs and symptoms (step 2)?

If yes to both identification questions, then:

  • Isolate (step 3):
    • Place patient in private room or separate enclosed area
      • Private bathroom or covered, bedside commode
    • Only essential personnel should evaluate patient and provide care
    • Level of personal protective equipment should be determined
      • Based upon patient’s clinical status (signs and symptoms)
  • Inform (step 4)
    • Immediately notify the hospital infection control program and other appropriate staff
    • Immediately notify the health department
  • Further evaluation and management will depend on the patient’s clinical status and other potential diagnoses (step 5).

 

Bottom line:

Whether the patient has Ebola or not, a well-developed response is necessary for patient management and public health preparedness. The fear of the disease is much more widespread and impactful than the disease itself.

 

See the full algorithm, with more details at: http://www.cdc.gov/vhf/ebola/pdf/ed-algorithm-management-patients-possible-ebola.pdf

Attachments



Heart Failure & Pulmonary Hypertension (Part I)

~50% of patients with heart failure & preserved ejection fraction (HFpEF) develop pulmonary hypertension (PH)

HFpEF with PH portends reduced survival and increased hospitalization rates compared to those without PH

HFpEF-PH is often confused with idiopathic pulmonary hypertension (IPAH) given the similar hemodynamics; differentiating them is challenging and requires careful consideration of clinical, radiologic, and hemodynamic data

 

 

PAH

HFpEF

Clinical parameters:

 Age

Typically 3rd–5th decade

Typically 6th–8th decade

 Comorbidities (HTN, HLD, DM, CAD)

Rare

Common

 Atrial arrhythmias

Rare

Common

 Obstructive sleep apnea

Rare

Common

Echocardiographic parameters:

 LA size/volume

Normal

Increased

 LV diastolic function

Normal to mildly abnormal

Moderate to severely abnormal

Hemodynamic parameters:

 Resting PAWP

Always <15 mmHg

May be < or >15 mmHg

 Response to volume

PAWP <15 mmHg (increase ≤5 mmHg)

PAWP >15 mmHg (increase >5 mmHg)

 Response to exercise

PAWP <15 mmHg (increase ≤5 mmHg)

PAWP >15 mmHg (increase >5 mmHg)

(Table reproduced from article)

 

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Title: Iliocostal syndrome

Category: Orthopedics

Keywords: Osteoporosis, elderly, (PubMed Search)

Posted: 10/25/2014 by Brian Corwell, MD
Click here to contact Brian Corwell, MD

Iliocostal syndrome aka iliocostal friction syndrome

Consider this entity in an elderly patient with osteoporosis with unexplained abdomen/flank or back pain.

Osteoporosis and/or vertebral compression fractures can result in a narrowing of the distance between .

the lowest anterior rib and the top of the iliac crest producing pain where this rib contacts the pelvis.

This can be perceived as side or back pain. This pain can restrict walking leading to a possible misdiagnosis of spinal stenosis. Treatment is with physical therapy and therapeutic injection.

http://www.caringmedical.com/wp-content/uploads/2013/09/iliocostalis.syndrome.jpg



Title: Tetracycline - oldie but goodie, remember its toxicity

Category: Toxicology

Keywords: tetracycline (PubMed Search)

Posted: 10/23/2014 by Fermin Barrueto (Updated: 11/14/2024)
Click here to contact Fermin Barrueto

Tetracycline has seen an increase in utilization due to its effectiveness in MRSA (check your local biogram). Remember its adverse effects/toxicity:

1) Photosensitivity 

2) Nephrogenic Diabetes Insipidus

3) Pseudotumor cerebri

4) Myopia

5) Deposits in calcifying bone/teeth - do not use in pediatrics



The 2013 neurosurgery guidelines mention two of the more controversial therapies used in spinal cord injuries:

- “MAP Push” (maintaining the patient’s MAP 85-90mmHg, which theoretically increases the blood flow to the penumbra): evidence for the particular MAP goal is not great, but studies show that ICU level monitoring for the first 7-14 days improves outcome as patients may have delayed cardiovascular or pulmonary instability

- Steroids are not recommended anymore (they were an “option” in the previous guidelines)

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Title: Choosing Wisely in the ICU

Category: Critical Care

Keywords: choosing wisely, icu, critical care (PubMed Search)

Posted: 10/21/2014 by Feras Khan, MD (Updated: 11/14/2024)
Click here to contact Feras Khan, MD

Choosing Wisely in the ICU

  • There is a general overuse of medical tests and treatments
  • This wastes healthcare resources
  • The Choosing Wisely Campaign was developed to have providers of different specialties choose medical services that should be questioned

The Critical Care Societies Collaborative came up with this list for ICU providers

1.     Don’t order diagnostic tests at regular intervals (such as every day) but rather in response to specific clinical questions. Do you really need a daily INR check or CBC check in all ICU patients? Really?

2.     Don’t transfuse red blood cells in hemodynamically stable, non-bleeding ICU patients with a hemoglobin concentration greater than 7 g/dl. See last week’s Pearl!

3.     Don’t use parental nutrition in adequately nourished critically ill patients within the first seven days of an ICU stay. TPN is the Cinnamon Toast Crunch of fungi.

4.     Don’t deeply sedate mechanically ventilated patients without a specific indication and without daily attempts to lighten sedation. Use as little as possible when you can.

5.     Don’t continue life support for patients at high risk for death or severely impaired functional recovery without offering patients and their families the alternative of care focused entirely on comfort. Engage families early in the hospital stay regarding aggressive life-sustaining treatments. Get palliative care involved in the ED!

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Title: What's the Diagnosis?

Category: Visual Diagnosis

Posted: 10/20/2014 by Haney Mallemat, MD (Updated: 11/4/2014)
Click here to contact Haney Mallemat, MD

Question

13 year-old right-hand dominant following assault with blunt object. What’s the diagnosis?

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