UMEM Educational Pearls

6-7% of kids presenting with upper respiratory symptoms will meet the definition for ABS.

The American Academy of Pediatrics (AAP) reviewed the literature and developed clinical practice guideline regarding the diagnosis and management of ABS in children and adolescents.

The AAP defines ABS as: persistent nasal discharge or daytime cough > 10 days OR a worsening course after initial improvement OR severe symptom onset with fever > 39C and purulent nasal discharge for 3 consecutive days.

No imaging is necessary with a normal neurological exam.

Treatment includes amoxicillin with or without clauvulinic acid (based on local resistance patterns) or observation for 3 days.

Optimal duration of antibiotics has not been well studied in children but durations of 10-28 days have been reported.

If symptoms are worsening or there is no improvement, change the antibiotic.

There is not enough evidence to make a recommendation on decongestants, antihistamines or nasal irrigation.

 

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Title: Acute Kidney Injury from Synthetic Cannabinoids

Category: Toxicology

Keywords: acute kidney injury, AKI, synthetic cannabinoid (PubMed Search)

Posted: 8/13/2014 by Bryan Hayes, PharmD (Updated: 8/14/2014)
Click here to contact Bryan Hayes, PharmD

Since synthetic cannabinoids arrived on the scene, we have become familiar with their sympathomimetic effects such as emesis, tachycardia, hypertension, agitation, hallucinations, and seizures.

Acute kidney injury is also being linked to synthetic cannabinoid use. Several clusters have been described in a handful of states, the most recent coming from Oregon with 9 patients.

AKI seems to be one more adverse effect to be on the lookout for when evaluating patients after synthetic cannabinoid use.

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Title: Should I Give My Patient with Septic Cardiomyopathy Fluids?

Category: Critical Care

Keywords: cardiomyopathy, sepsis, septic shock, pressors, inotropes, epinephrine, norepinephrine, dobutamine (PubMed Search)

Posted: 8/12/2014 by John Greenwood, MD
Click here to contact John Greenwood, MD

 

Should I Give My Patient with Septic Cardiomyopathy Fluids? 

 

The incidence of acute LV dysfunction in septic shock is estimated to occur in 18 - 46% of patients within the first 24 hours of shock.  Unlike the "classic" pattern of cardiogenic shock where LV filling pressure is high, in septic shock there are normal or low LV filling pressures.

Three therapeutic options should be strongly considered in the patient with a septic cardiomyopathy [CM]:

  • FLUIDS:  Most patients with septic CM need fluids to restore adequate preload/afterload.  Severe vasoplegia requires volume resuscitation - even if the bedside ECHO suggests reduced contractility. Give fluids generously.
  • Vasopressors: Catecholamine supplementation (norepi) improves patient's preload & afterload, but can often unmask septic CM. Consider epinephrine as a second line agent (over vasopressin) for inotropic support.
  • Inotropes: Consider adding epinephrine (1 to 5 mcg/min) or dobutamine (start at 1-5 mcg/kg/min) to target an improved cardiac index (>2.5 L/min/m2) or ScVO2 > 70%.

 

 

 

 

 

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Question

30 year-old female with complains of night sweats and painful lesions on her fingertips. What’s the diagnosis and list some things to have in the differential diagnosis?

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- Toxic effects of tricyclic antidepressants (TCA) are result of the following 4 pharmacologic properties:

  1.  Inhibition of norepinephrine & serotonin reuptake --> resultant seizure

2.  Anticholinergic activity --> resultant altered mental status, tachycardia, mydriasis, ileus

3.  Direct alpha-adrenergic blockade --> resultant hypotension

4.  Cardiac myocyte sodium channel blockade --> resultant widened QRS

- A QRS interval greater than 100 milliseconds has ~30% chance of developing seizures and ~15% chance of developing a life-threatening cardiac arrhythmia.

- A QRS interval greater than 160 milliseconds increases the chance of ventricular arrhythmias to greater than 50%.

- Clinical pearl: A very wide complex ventricular rhythm, concomitant hypotension and/or seizure disorder is suspicious for toxic ingestion and standard ACLS algorithm will not suffice, treatment must address the underlying culprit (i.e. TCA --> Tx. fluids, vasopressors, sodium bicarbonate, and intravenous lipid emulsion).

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Return to Play After Infectious Mononucleosis (IM)

-Long incubation period make it difficult to determine source or onset

Presentation often atypical with nothing more than fatigue, decreased energy or decreased athletic performance.

DDX: Herpes simplex, HIV, CMV, toxo and strep (simultaneous infection may be seen in up to 30%)

Classic 3 to 5 day prodromal period (malaise, fatigue, anorexia)

Symptoms then progress into the classic “triad” of IM

                Fever, pharyngitis, lymphadenopathy (esp. posterior cervical nodes)

May also have posterior palantine petechiae ( of cases), jaundice, exudative pharyngitis, rash and splenomegaly)

Rash (10% to 40%), transient, generalized maculopapular, petechial or urticarial)

                Most commonly seen in patients treated with PCN antibiotics

Splenomegaly is an important complication in the athletic population

Mononucleosis makes the spleen susceptible to rupture (traumatic or spontaneous)

                - Lymphocytic proliferation enlarges the spleen beyond protection from the ribs

                - Physical examination has been shown to be unreliable for determining splenomegaly

                - Highest risk is in the first 21 days (rare after 28 days)

Ultrasound is the modality of choice

                -Splenomegaly peaks at 2 to 3 weeks and resolves in the majority between 4 to 6 weeks

Return to play is generally allowed after 4 weeks from diagnosis in the absence of splenomegaly and resolution of symptoms.



Title: Cold Exposure and Associated Conditions

Category: International EM

Keywords: hypothermia, cold, environmental (PubMed Search)

Posted: 8/9/2014 by Jon Mark Hirshon, PhD, MPH, MD (Updated: 11/14/2024)
Click here to contact Jon Mark Hirshon, PhD, MPH, MD

General Information:

Hypothermia is when the body’s core temperature is less than 35º C. Often thought as a winter disease, it can occur in nearly any climate or weather condition. However, a number of cold related conditions can occur without a drop in core body temperature.

 

Specific Cold Related Conditions:

  • Frostnip
    • Condition: Ice crystal deposited in the dermis
    • Exposure: Freezing, damp exposure over hours to days
    • Treatment: Warm water (37º-41ºC) immersion with movement of affected area for 15-30 minutes

 

  • Frostbite
    • Condition: Frozen skin surface with damage to dermis and deeper structures
    • Exposure: Freezing, damp exposure over hours to days
    • Treatment: Warm water (37º-41ºC) immersion with movement of affected area for 15-30 minutes

 

  • Trench foot
    • Condition: Tissue necrosis without freezing
    • Exposure: Cold water exposure for hours to days
    • Treatment: Warm water (37º-41ºC) immersion with movement of affected area for 15-30 minutes

 

  • Chillblains
    • Condition: Epidermis repeatedly partially frozen and thawed
    • Exposure: Chronic cold, dry wind exposure over weeks
    • Treatment: Calcium-channel blockers can provide pain relief and decrease necrosis

 

Bottom line:

Remember that cold related injuries can occur without core hypothermia. Don’t forget the tetanus and antibiotics, as indicated.

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Some Pearls concerning Strep Throat in Kids:
  • Only treat strep pharyngitis after confirmed via rapid antigen test or culture
  • Remember the rapid antigen test has high specificity, but low sensitivity.  All negative rapid antigen tests should be followed up with a confirmatory culture
  • Traditionally, strep pharyngitis was treated with penicillin V, 250mg PO tid for children and 500 mg tid for adolescents. This was then changed to bid dosing.
  • Now, consider treating with amoxicillin, 50mg/kg once daily (max 1000mg). Once daily dosing and better taste improve compliance 
 

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There are many ventilator modes to choose from, but almost every mode can be distilled down to its basic principles by understanding the “Three T's of Mechanical Ventilation”

Trigger: You must determine whether the vent or patient will trigger a mechanical breath. For example, machine-triggered breaths (a.k.a. control mode of ventilation) are used for paralyzed patients and will deliver a breath after a period of time has elapsed (e.g., if RR is 10/min, then a breath is given every 6 seconds). On the other hand, if a patient’s respiratory drive is intact (a.k.a. assist-mode) than the patient triggers the breath when the vent detects a patient induced change in airflow or airway pressure. These two modes can also be mixed together.

Target: Mechanical breaths must have a specific target, either a target airway pressure or a tidal volume. Because pressure and volume are directly related, pick the variable you want to target and the other parameter will vary depending on the patient’s intrinsic physiology. For example, if you choose to target a specific tidal volume, we may get one plateau pressure in a patient with normal lungs, but a higher plateau pressure in another patient with stiffer lungs.

Terminate: You must decide when the mechanical breath (i.e., inspiration) terminates and expiration begins. Termination occurs: 1) after a set inspiratory time has elapsed in certain pressure-targeted modes, 2) when a predefined target volume has been achieved (i.e., volume-cycled modes), or 3) when airflow has been reduced by a certain percentage (as in pressure-support ventilation; to be discussed separately)

Let’s put this all together by looking at an example: pressure control ventilation (rate = 12/min and target pressure 20cm H20). Trigger: Because this is a “control”, not assist mode, the machine will trigger a breath 12 times per minute or every 5 seconds. Target: Here we chose to have pressure be the target, so when the ventilator triggers a breath it will deliver a constant airway pressure of 20 cmH2O until we tell the vent terminate that breath. Terminate: the constant airway pressure will be turned off after a fixed period of time has elapsed; for this example we will set the inspiratory time as 1 second, then expiration begins. Now, after a few vent breaths we will observe the results of our settings and reassess; if the resulting tidal volume is lower than what we wanted, we will increase the target pressure to increase the tidal volume. If the tidal volume is higher than what we wanted, we will reduce the target pressure to reduce the tidal volume. We can also tweak the inspiratory time to manipulate the tidal volume, but this does so to a lesser degree.

Try to break down your favorite modes of ventilation using the Three T’s and see if this helps you understand vent modes better. 

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Question

40 year-old female presents with painful lesions and ulcers on lower extremities. She has had this before, but never to this extent. She also has a history of DVT. What’s the diagnosis?

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Advances in Hypertrophic Cardiomyopathy (HCM)

- HCM is a genetically transmitted autosomal dominant disorder with two variants: hypertrophic obstructive cardiomyopathy (HOCM), also known as idiopathic hypertrophic subaortic stenosis (IHSS) or asymmetric septal hypertrophy, and non-obstructive hypertrophic cardiomyopathy (HNCM), also known as Yamaguchi syndrome.

- The most serious complication of both variants of HCM is sudden cardiac death (SCD) and end-stage heart failure, which rapidly progresses to cardiac death after its occurrence.

- Beta-blockers (1st line) and non-dihydropyridine calcium channel blockers are effective at improving clinical symptoms (syncope, dyspnea, chest pain, and exertional intolerance, etc.) however neither alone nor combined halt the progressive LV remodeling and prevent end-stage heart failure.

- Cardiac transplantation is the only treatment available for end-stage heart failure, but must occur before the onset of pulmonary hypertension, kidney malfunction, and thromboembolism for success.

- Class Ia anti-arrhythmic, disopyramide has been shown to be effective for symptomatic improvement (NYHA classification), but does not improve overall LV function or hypertrophy.

- A recent study found that another class Ia anti-arrhythmic, cibenzoline has been shown not only to reduce symptoms, but also improved LV diastolic dysfunction and induced a regression of LV hypertrophy. In this study cibenzoline has halted the progression of HCM to end-stage heart failure. 

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Title: Is High-Dose Oseltamivir (Tamiflu) Indicated for Critically Ill Patients?

Category: Pharmacology & Therapeutics

Keywords: oseltamivir, critically ill, high-dose, influenza, Tamiflu (PubMed Search)

Posted: 7/28/2014 by Bryan Hayes, PharmD (Updated: 8/2/2014)
Click here to contact Bryan Hayes, PharmD

Despite the lack of strong evidence to support the recommendation, the severity of the 2009 influenza pandemic prompted the World Health Organization (WHO) to advise that higher doses of oseltamivir (150 mg twice daily) and longer treatment regimens (> 5 days) should be considered when treating severe or progressive illness.

So, does the data support higher dosing in critically ill influenza patients?

A new systematic review concluded that "the small body of literature available in humans does not support routine use of high-dose oseltamivir in critically ill patients."

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Title: Not your ordinary Bath product

Category: Toxicology

Keywords: Bath salts, mephedrone, agitated delirium (PubMed Search)

Posted: 7/31/2014 by Kishan Kapadia, DO
Click here to contact Kishan Kapadia, DO

Bath salts (synthetic cathinones) commonly contain multipe synthetic drugs and can be ingested, smoked, or administered intravenously.  The designer stimulant mephedrone (4-methylcathinone) is among the most popular of the derivatives of the naturally occurring psychostimulant cathinone.  Bath salt use is on the rise and is responsible for a large number of ED visits.

In spite of their ban, bath salts are still available over the counter in specialty shops and through the Internet with common product names such as: "Ivory Wave," "Cloud 9," "Purple Wars," "Vanilla Sky," "Bliss," etc.  They are commonly marketed with the disclaimer, "not for human consumption.

Their presentation mimics other sympathetic drugs through pathways similar to amphetamines.  The primary psychological effects have a duration of roughly 3-4 hours, with physiologic effects lasting from 6-8 hours.

Physical Effects                        Behavioral & Mental Status Effects
Tachycardia Agitation
Hypertension Paranoia
Dysrhythmias Hallucinations
Hyperthermia Psychosis
Seizures Violent behavior
Sweating Delusions

Management is largely supportive and includes IV hydration, benzodiazepines, and close monitoring in the ICU setting.

 

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Title: Deadly Ebola- Coming to a hospital near you?

Category: International EM

Keywords: Ebola, hemorrhagic fever, international (PubMed Search)

Posted: 7/30/2014 by Jon Mark Hirshon, PhD, MPH, MD (Updated: 11/14/2024)
Click here to contact Jon Mark Hirshon, PhD, MPH, MD

General Information:

Ebola is a deadly hemorrhagic fever of the virus family Filoviridae

  • The largest outbreak known is currently affecting multiple countries in West Africa (especially Guinea, Liberia and Sierra Leone).
  • As of July 23rd, the WHO has recorded a total of 1,201 cases and 672 deaths (case fatality rate of 56%).

 

Clinical Information:

  • Spread by close contact (direct contact with body fluids)
    • Primarily seen in family members of those infected and health care workers
  • Incubation is usually from 8-10 days (can be from 2-21 days)
  • Typical signs and symptoms include: fever, headaches, muscle/joint aches, abdominal pain, vomiting, diarrhea
  • Additionally, some patients may experience: rash, red eyes, chest pain, difficulty breathing, difficulty swallowing, bleeding from multiple areas

 

Treatment and Public Health

  • Supportive care and treatment of complications
  • Contact isolation
  • Immediately report to the local health authorities

 

Bottom Line:

            While the likelihood of general dissemination to the general U.S. population is very low, U.S. healthcare workers need to be aware and alert for the signs and symptoms of Ebola for patients recently returned from West Africa.

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Title: I just gave IM Epi for anaphylaxis, how long do I need to observe the patient?

Category: Critical Care

Keywords: epinephrine, im, anaphylaxis, allergic reaction, observation (PubMed Search)

Posted: 7/29/2014 by Feras Khan, MD
Click here to contact Feras Khan, MD

Observation after giving IM Epi for allergic reactions or anaphylaxis

Background

  • Common practice is to observe patients who receive epinephrine for allergic reactions or anaphylaxis for several hours post-administration
  • This can be from 4-24 hours depending on the institution
  • This is to monitor for a biphasic reaction

Question

  • Do we need to observe these patients?
  • And if so, for how long?

Meta-analysis

  • 2 urban Canadian EDs
  • 5 year period
  • Primary outcome was the amount of patients with a clinically important biphasic reaction
  • Secondary outcome was mortality

Results

  • 2819 encounters: 496 anaphylactic + 2323 allergic reactions
  • 5 clinically important biphasic reactions (0.18%; 95% CI 0% to 0.17%)
  • No fatalities
  • Biphasic reactions tended to happen several hours (>24hrs) after ED discharge

Limitations

  • If patients did not return to an ED in the region, then they would not be identified as a possible biphasic reaction

What to do?

  • You can probably discharge most patients whose symptoms have resolved without a prolonged observation period (<4hrs)
  • Patients with ongoing anaphylaxis and allergic reaction, should be observed longer or admitted
  • Biphasic reactions are very rare

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Question

2-day old baby boy presents with forceful vomiting of entire feeds, bloated belly, and has not passed stools since birth. What's the diagnosis?

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Title: HIV & Atherosclerosis

Category: Cardiology

Posted: 7/27/2014 by Semhar Tewelde, MD (Updated: 11/14/2024)
Click here to contact Semhar Tewelde, MD

HIV & Atherosclerosis

Advances in antiretroviral treatment has increased the life expectancy of patients with HIV significantly, AIDS-related deaths have fallen by 30% since they peaked in 2005.

HIV infection predisposes to a chronic inflammatory and immunologic dysfunctional state, subsequent highly active antiretroviral treatment (HAART) results in metabolic changes and dyslipidemia.

In the post-HAART era, CAD is now considered to be the main cause of heart failure in HIV-infected patients, superseding the prior most common etiologies myocarditis and opportunistic infections.

The presentation of CAD in HIV-infected patients is largely similar to that in the general population with the exception is that they present at a younger age.

Certain antiretroviral agents specifically protease inhibitors have conventionally been associated with lipid dysfunction, further complicating the HIV-infected patients milieu.

Recent research has shown that a C-C chemokine receptor-type 5 (CCR5) antagonists has emerged as a potential target both as an antiretroviral agent as well as in the process of arresting atherogenesis, but warrants more research.

 

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Title: Cervical Cord Neuropraxia (CCN)

Category: Orthopedics

Keywords: Spinal Cord injury (PubMed Search)

Posted: 7/13/2014 by Brian Corwell, MD (Updated: 7/23/2014)
Click here to contact Brian Corwell, MD

Cervical Cord Neuropraxia (CCN)

A concussion of the spinal cord as a result of an on-field collision.

A transient motor and/or sensory disturbance, lasting less than 24 hours.

A distinct and separate entity from spinal cord injury resulting in quadriplegia

Incidence 7.3 per 10,000 athletes

Approx. 50% of players experiencing CCN who return to play, have a second episode

The risk of this second episode is inversely proportional to the size of the cervical bony canal

Athletes with narrow canal diameter are more likely to have a 2nd episode

               Those with normal canal diameter (14 mm on MRI) have a 5% risk

               Those with a narrow canal (9 mm or less)) have a greater than 50% risk.

Whether repeat episodes lead to permanent spinal cord injury is unknown

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Title: Ondansetron and QT Prolongation - Recent Ann EM article

Category: Toxicology

Keywords: ondansetron (PubMed Search)

Posted: 7/24/2014 by Fermin Barrueto (Updated: 11/14/2024)
Click here to contact Fermin Barrueto


Ondansetron is a highly effective anti-emetic that, since it has gone generic, is also quite inexpensive. There have been some reports of QT prolongation and cardiac arrhythmias especially with the high-dose 32mg IV dose for chemotherapy patients.

Is still safe in our ED population? A large systematic review was done in this month's Ann Emerg Med July 2014,p19-31.

Take Home Points:

1) No reports of arrhythmia associated with single dose administration identified

2) 80% of 60 unique reports were IV

3) 83% had significant PMH or already on a QT prolonging drug

Conclusion: Ondansetron doesn't warrant routine EKG or electrolyt screening in oral administration.High dose IV and High Risk patients do require more vigilance with EKG and electrolyte screening.



Title: Does Everyone with a Traumatic Head Bleed Need to go to the ICU?

Category: Neurology

Keywords: intracranial hemorrhage, ICU, clinical decision rule (PubMed Search)

Posted: 7/23/2014 by Danya Khoujah, MBBS
Click here to contact Danya Khoujah, MBBS

Maybe not! A new prospective study looked at 600 adult trauma patients presenting with mild traumatic intracranial hemorrhage (with a GCS 13-15), and derived a clinical instrument that predicted the need for a “critical care intervention” (and therefore needing an ICU level of care). These interventions included intubation, neurosurgical intervention and need for invasive monitoring, among other things.

The derived instrument consisted of 4 variables:

1.     GCS less than 15

2.     Non-isolated head injury

3.     Age 65 years or older

4.     Evidence of swelling or shift on the initial head CT

The presence of at least one of these variables predicted the need for critical intervention, identifying 114 of the 116 patients who actually did require it, making it 98.3% sensitive.

This clinical decision rule is yet to be externally validated

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