There are a few available options for treatment of visual loss due to idiopathic intracranial hypertension (IIH). The Idiopathic Intracranial Hypertension Treatment Trial (IIHTT), the first randomized, prospective, placebo-controlled trial for the treatment of patients with visual loss from IIH, which results were published earlier this year, provided substantial evidence for the first 2 options.
1. Weight loss
2. Carbonic anhydrase inhibitors, such as Acetazolamide
3. Therapeutic lumbar puncture (reserved for pregnant patients or for occasional flare-ups)
4. Surgery:
a. Optic nerve sheath fenestration (ONSF): visual acuity and fields improve in most cases, but symptoms may recur. Benefit? No hardware!
b. Shunts: ventriculoperitoneal (VP) and lumboperitoneal (LP) shunts are the most frequently used. No clear benefit for one over the other. VP shunts may be programmable.
c. Cerebral venous stenting: endovascular stenting of the transverse sinus may improve the symptoms in some people.
BONUS PEARL: The headache does not correlate with the lumbar opening pressure, degree of papilledema or amount of visual loss. None of the above-mentioned management strategies is meant for the treatment of the headache alone. For that, medical management with standard symptomatic treatments, avoiding opiates and barbiturates, is recommended. Surgery is not recommended for headache alone.
Running a successful resuscitation not only means doing everything right, but also remembering all the things that can go wrong. A.E.I.O.U. is a simple mnemonic that can help you remember the simple things that are sometimes forgotten during a medical resuscitation.
A – Advanced airway equipment to bedside, as well as checking the correct placement of the Airway if a patient is intubated in the field. Also consider adding another A, for Arterial line; early placement can help with pulse checks and an accurate assessment of blood pressure should there be return of spontaneous circulation (ROSC); the femoral site is fast and accurate.
E – End-tidal CO2 (ETCO2) helps detect ROSC. Ask for the ETCO2 monitor to be set up right after you receive notification of an arrest in transit; ETCO2 requires time to set-up / calibrate
I – Intraosseous line(s); compared to peripheral or central venous access, IO’s are faster, safer, and any medication can be administered through it, including vasopressors / inotropes.
O – Order (i.e., “who’s who in the Resus room?); You may be the team leader or you may be assisting, but it is important that you, and everyone else in the room, know their role prior patient arrival. If you are leading the resus, be sure everyone knows who you are, and assign everyone in the room a specific task (e.g., chest compressions, IO placement, etc.). If you are assisting and have not been assigned a task, ask the resus leader what you can do to help. If there is nothing immediate for you to do then take the initiative to de-clutter the room and step outside; be nearby and ready to help, if needed.
U – Ultrasound; can help prognosticate and detect reversible causes (e.g., pericardial tamponade). Have the ultrasound machine in the room prior to patient arrival. It should be powered on, with the proper probe connected, and in the proper mode. The most experienced ultrasonographer should scan the patient during a pulse check; experience is vital because hands-off time should be minimized.
*Tips for the Resuscitationist (#TFTR) is a new series to help you to better manage your critically ill patients. Do you have an idea for a topic or do you have a tip you would like to share? Send it to us via twitter @criticalcarenow (use (#TFTR)). You can also email us here.
Patient with syncope and then falls down the stairs. What's the diagnosis? (hint: be very,very careful)
Patent Foramen Ovale: To Close or Not to Close
- Patent foramen ovale (PFO) is associated with a 3-fold increased risk for recurrent stroke, yet current guidelines only recommends “consideration” of PFO closure after a second cryptogenic stroke.
- Studies have demonstrated reductions in recurrent neurologic events with transcatheter PFO closure compared with medical therapy alone.
- Until recently the cost-effectiveness of PFO closure has not been described.
- Although PFO closure was found to be immediately more costly per patient closure, it reached cost-effectiveness at ~2.5 years of follow-up.
- Closure of PFO is both beneficial in terms of risk-benefit and cost-effectiveness strategy, especially as cryptogenic stroke typically affects the young.
Knee dislocation 2
Most commonly occur after MVCs but also seen after falls, industrial accidents and sports related trauma.
Up to 50% of knee dislocations will have spontaneously reduced by time of presentation to the ED.
Strongly consider a spontaneously reduced knee dislocation in those with a significant mechanism of injury in the setting of multidirectional instability (3 or more ligaments torn).
A thorough neurovascular examination is a must due to the risk of vascular (34%)(5-79%) and nerve (23%)(16-40%) injuries. There is a must higher incidence of these injuries in high force trauma such as from a MVC. The popliteal artery and common peroneal nerve are at the greatest risk
Though the absence of distal pulses suggests vascular injury, the presence of pulses cannot be used as evidence of the lack of a vascular injury.
After reduction, the knee should be immobilized in 15-20° of flexion in a knee immobilizer.
Background: As noted in a previous pearl (November 5, 2014), the Centers for Disease Control and Prevention (CDC) classifies potential bioterrorism agents into three categories. Category B & C agents are of less priority than the previously discussed Category A agents.
Category B: Second highest priority agents. These agents:
These Agents/Diseases include:
•Brucellosis (Brucella species)
•Epsilon toxin of Clostridium perfringens
•Food safety threats (e.g., Salmonella species, Escherichia coli O157:H7, Shigella)
•Glanders (Burkholderia mallei)
•Melioidosis (Burkholderia pseudomallei)
•Psittacosis (Chlamydia psittaci)
•Q fever (Coxiella burnetii)
•Ricin toxin from Ricinus communis (castor beans)
•Staphylococcal enterotoxin B
•Typhus fever (Rickettsia prowazekii)
•Viral encephalitis (alphaviruses [e.g., Venezuelan equine encephalitis, eastern equine encephalitis, western equine encephalitis])
•Water safety threats (e.g., Vibrio cholerae, Cryptosporidium parvum)
Category C agents: Third highest priority agents. These include emerging pathogens, such as hantavirus and Nipah virus, which could be potentially engineered for mass dissemination in the future.
Bottom Line: While in general of less concern, bioterrorism agents in Category B & C remain of significant risk. Many of these diseases still occur in various parts of the globe including the United States.
The pattern of prescription drug abuse continues to center around semisynthetic opioids like oxycodone and hydrocodone. Federal regulations have now raised hydrocodone to a schedule II drug like oxycodone. Despite efforts, the slope for natural and semisynthetic opioids remains steep. The ED measures of education, limit prescriptions for acute pain, minimize number of days/pills prescribed and utlize the prescription drug monitoring program are some basics that can assist you in better prescribing habits.
Tips for the inpatient management of community acquired pneumonia
Patient presents with dyspnea & hypoxemia (pulse oximeter is 80%). The "stat" CXR is delayed, but ultrasound is not. What's the diagnosis and what are some differential diagnoses?
Management of Felons
For good photos of the incision technique please visit the reference article listed.
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.
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:
DDx of anisocoria with poorly or non-reactive pupil:
Aminoglycosides in Critically Ill Patients
Parasternal long-axis of two different patients. What is the:
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.
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.
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
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:
Specific Category A Agents/Diseases:
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.
