UMEM Educational Pearls

Several studies have described factors associated with peri-intubation cardiac arrest in the adult population. Factors such as pre-intubation hypotension, elevated BMI, and elevated shock index (HR/SBP) have been associated with cardiac arrest following intubation in adult ED patients. Given the differences in anatomy and physiology in children, one may expect risk factors for peri-intubation cardiac arrest to differ in children.

A number of studies have examined factors associated with peri-intubation cardiac arrest in the pediatric population, but these have remained limited to the inpatient setting. These studies have found that, in hospitalized and PICU patients, the factors of hemodynamic instability, hypoxemia, history of difficult airway, pre-existing cardiac disease, and higher number of intubation attempts are associated with peri-intubation cardiac arrest. A paucity of literature exists on this airway complication in pediatric ED patients.

Pokrajac et al. provide the first study on risk factors for peri-intubation cardiac arrest in pediatric ED patients. These authors conducted a retrospective nested case-control study of pediatric patients (ages <18 years) who presented to a tertiary children’s hospital in San Diego from 2009-2017. Cases included patients who had a cardiac arrest within 20 minutes after the start of endotracheal intubation. Authors selected a number of predictors to examine, including age-adjusted hemodynamic variables, capillary refill, pulse oximetry, patient characteristics, intubation-related factors, and pre-intubation interventions.

The authors found the following:

-       Demographic characteristics:

o   Patients with peri-intubation cardiac arrest were significantly younger (<1 year of age), shorter, and more likely to have history of preexisting pulmonary disease.

-       Incident characteristics:

o   Patients with peri-intubation cardiac arrest were more likely to have:

       -Low or unobtainable SBP or DBP

       -Delayed capillary refill time

       -Low (<92%) or unobtainable pre-intubation SpO2

        -More than 1 intubation attempt than controls

        -No paralytic or sedative agent prior to intubation

o   Patients with peri-intubation cardiac arrest were NOT more likely to have increases in age-adjusted HR or pediatric shock index in comparison to controls.

o   The strongest clinical predictor for peri-intubation cardiac arrest was pre-intubation hypoxia or unobtainable SpO2. This fact is supported by children’s increased metabolic rate and thus increased oxygen consumption. This physiologic finding explains the shorter amount of time it takes children to develop acute hypoxia, particularly in the peri-intubation setting.

Bottom line: If planning to intubate a pediatric patient in the ED, keep in mind that pre-intubation systolic or diastolic hypotension, delayed capillary refill time, multiple intubation attempts, and hypoxia in particular may increase the risk for peri-intubation cardiac arrest. Consider providing apneic oxygenation to minimize hypoxemia prior to intubation.

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Category: Toxicology

Title: Ethanol exposures among infants in the US: 2009-2018

Keywords: ethanol exposure, infant, national poison data system. (PubMed Search)

Posted: 12/3/2020 by Hong Kim, MD, MPH
Click here to contact Hong Kim, MD, MPH

 

Ethanol exposure among young children can result in significant morbidity. Infants and young children can be exposed to ethanol in many different ways: exploratory ingestion, mixed in formula-both intentionally and unintentionally, etc. 

A recently published study used national poison data system to characterize the ethanol exposure among infants < 12 months of age.

 

Results:

Between 2009-2018, 1,818 ethanol exposures among infants were reported. Oral ingestion was the most common (96.7%; n=1738). Annual number of ethanol exposure increased by 37.5% each year. 

Exposure site

  • Residence: 96.7% (n=1,758)
  • Public are/workplace or school: 1.6% (n=29)

Age

  • 0-2 months: 16.3% (n=296)
  • 3-5 months: 19.6% (n=357)
  • 6-8 months: 18.8% (n=341)
  • 9-11 months: 45.3% (n=824)

Clinically significant effects

  • Coma: 20
  • Hypoglycemia: 16
  • Respiratory depression: 15
  • Seizures: 13
  • Hypothermia: 9
  • Cardiac arrest: 4
  • Respiratory arrest: 3
  • Death: 5

563 infants (31%) were evaluated at hospital

38% (n=214) of the exposures were hospitalized

0-5 months of age 

  • higher odds of admission: non-critical (OR: 2.35, 95% CI: 1.41-3.92) or critical care unit (OR: 2.39; 95% CI:1.5-3.79)
  • higher odds of serious outcome (OR: 4.65; 95% IC: 3.18-6.79)

 

Conclusion

Ethanol exposure among infants is increasing each year and associated with serious clinical effects.  

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Category: Orthopedics

Title: Anterior shoulder pain

Keywords: Shoulder, biceps, tendon (PubMed Search)

Posted: 11/28/2020 by Brian Corwell, MD (Updated: 12/4/2020)
Click here to contact Brian Corwell, MD

A 25 year old athlete presents to the ED with right anterior shoulder pain.

Pain radiates into proximal biceps.

It is worse with heavy lifting and especially “pulling” exercises at the gym.

 

How do we evaluate for biceps tendonitis?

  1. Tenderness to palpation in the bicipital groove
  2. Speed’s test
  3. Yergason’s test

 

Pathology is often the long head of the biceps

https://physioworks.com.au/wp-content/uploads/2019/12/biceps-tendonitis.jpg

Start by palpating this area and attempt to reproduce the discomfort

Speed’s test

 

Yergason’s test

  • Arm is placed to patient’s side, in pronation and flexed to 90 degrees at elbow
  • Patient attempts to supinate and externally rotate arm against resistance
  • https://youtu.be/rQ2Mp6aSi88

 

 


Category: Pediatrics

Title: Helpful hints for the pediatric prepubescent genitourinary exam

Keywords: vaginitis, vaginal discharge (PubMed Search)

Posted: 11/20/2020 by Jenny Guyther, MD (Updated: 12/4/2020)
Click here to contact Jenny Guyther, MD

To determine if the child is prepubescent, look for the lack of pubic hair, clitoral size, configuration of the hymen, breast development, and axillary hair growth. A Tanner stage of 1 would be consistent with prepuberty.

The proper positioning for the physical exam will allow the child to be comfortable and the examiner to obtain an adequate view including up to one-third of the vagina.

If the child is small enough, they can lay in the parent’s lap. For a larger child, you can have the parent sit in the bed with the patient or stand near the child’s head. Engage child life if available.

The frog leg position with gentle downward and outward traction of the labia at the 5- and 7-o’clock positions provides the optimal view.

The knee to chest position is helpful when further evaluation is needed.

A rectovaginal exam is useful for evaluation of masses or foreign body only and is not routinely needed. Place the examiner’s little finger in the rectum and the other hand on the abdomen and palpate.

The use of a vaginal speculum is rarely needed in prepubertal children; if it is needed, perform the exam under anesthesia.

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Summary

Our group performed a meta-analysis to assess whether it is safe to infuse vasopressor through peripheral venous catheters.  We identified 9 studies with a total of 1835 patients.  The prevalence of complications among the pooled patient population was 9%.  Up to 96% of the complications was extravasation and almost no complications required any treatment.

A few studies reported safe infusion of norepinephrine up to 0.1 mcg/kg/min for up to 24 hours.

In exploratory meta-regression, catheter size 20 or larger was negatively associated with the rate of complications.

We also observed that studies that were published within the past 5 years reported significantly lower rate of complications from older studies.  This suggested that with careful planning and monitoring, it is safe to start vasopressor through peripheral IV.

Limitation

most of the included studies were observational. No studies had enough power to statistically analyze any variables that could predict complications.

Bottom line: we should start vasopressor as soon as indicated, if we have good, reliable IV access.

 

 

 

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Significance: 
There have been few high-quality studies regarding slow continuous infusion (SCI) of hypertonic vs. rapid intermittent bolus (RIB) therapy for patients with symptomatic hyponatremia
 
Study Design:
Multicenter, open-label RCT with 178 patients (both ED and inpatient) with corrected Na of 125 mml/L or lower with moderate/severe symptoms
-Moderate symptoms:  nausea, headache, drowsiness, general weakness, and malaise
-Severe symptoms: vomiting, stupor, seizure, and coma (Glasgow Coma Scale [GCS] score ≤8)
Relevant excluded patient populations: liver disease/cirrhotics, uncontrolled diabetics, primary polydypsia, anuric, hypotensive
 
Intervention:
Slow continuous infusion (SCI) of hypertonic vs. Rapid intermittent bolus (RIB) therapy 
(see treatment algorithms  for specifics)
 
Results:
Primary outcome: No difference in rates of overcorrection 
15 of 87 (17.2%) patients in the RIB group vs.  22 of 91 (24.2%) patients in the SCI group 
-(absolute risk difference, −6.9% [95% CI, −18.8% to 4.9%]; P = .26)
 
Other outcomes:
RIB group showed a lower incidence of relowering treatment than the SCI group 
-(absolute risk difference, −15.8% [95% CI, −30.3% to −1.3%]; P = .04; NNT, 6.3)
 
RIB group had higher proportion of patients achieving target correction rate within 1 hour than the SCI group 
-(absolute risk difference, 14.6% [95% CI, 2%-27.2%]; P = .02; NNT, 6.8)
 
No significant differences between the groups were observed in:
- symptoms at 24 and 48 hours after treatment initiation
- first time to an increase in sNa 5 mmol/L or greater after treatment initiation
- incidence of target correction rate
- time from treatment initiation to achievement of sNa greater than 130 mmol/L
- length of hospital stay 
 
There were no cases of osmotic demyelination syndrome in either group
 
Take-home point:
Rapid intermittent boluses of hypertonic saline may be just as effective as slow continuous infusions for certain patient populations with moderate/severe symptomatic hyponatremia (and may actually have decreased rates of need for re-lowering treatment)
 
Limitations:
-smaller study
-high number of dropout due to protocol violation
-remember that ODS is multifactorial (liver disease, chronic alcoholism, malnutrition)

 

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Category: Neurology

Title: What Makes a Headache a Migraine?

Keywords: migraine, headache, diagnosis, treatment, prevention (PubMed Search)

Posted: 11/11/2020 by WanTsu Wendy Chang, MD (Updated: 11/13/2020)
Click here to contact WanTsu Wendy Chang, MD

  • Migraine is the 2nd most common neurologic disorder after tension headache and accounts for more disability than all other neurologic disorders combined.
  • Diagnosis is clinical and defined by at least 5 episodes of headache that meet the following criteria:
    • Duration of 4 to 72 hours (when untreated or unsuccessfully treated)
    • At least 2 characteristics: unilateral, pulsating, moderate-to-severe pain intensity, aggravated by physical activity
    • Accompanied by at least 1 symptom: nausea, vomiting, photophobia, phonophobia
  • Aura symptoms must be fully reversible and may be visual, sensory, speech/language, motor, brainstem, or retinal.
  • Early treatment while the headache is still mild include NSAIDs followed by triptans.
    • Opioids and barbiturates are not recommended due to adverse effects and risk of dependency.
  • Preventive treatment is recommended for patients who have at least 2 migraine days per month and whose lives are adversely affected.
    • Common therapies include antihypertensive agents (e.g. propranolol), antidepressants (e.g. amitriptyline), anticonvulsants (e.g. topiramate, valproate), and calcium-channel blockers (flunarizine).

Bottom Line: Migraine is a common and debilitating condition that benefits from early treatment. Consider initiating preventive therapy for patients who experience at least 2 migraine days per month and adverse effects despite treatment.

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Allergy documentation in the medical record is not always clear, nor does it provide clarifying details to understand timing and severity of beta-lactam allergies.  Approximately 8-10% of the population report beta-lactam allergies and 90% of those are not IgE-mediated reactions that would preclude the use of this class.  
 
A recent retrospective, single-center study of 438 patients was performed to assess the impact of these allergies on mortality and time to effective antibiotics in sepsis or septic shock.
 
-26% of the patients reported a beta-lactam allergy
-No significant differences with respect to primary source of infection (bacteremia and UTI most common)
-No difference in incidence of prior resistant organisms
 
Results:
-Overall, there was no difference in the combined endpoint of in-hospital mortality or transfer to hospice, time to antibiotics, ICU length of stay, hospital length of stay, and total hospital cost
-There was a significant difference in the susceptibility of the cultured organism to the initial antibiotic therapy in patients without a beta-lactam allergy (78% vs 57% p=0.009)
 
Bottom line:
Clarify all beta-lactam allergies in the medical record when they are encountered as they may impact care during the hospitalization or in subsequent encounters.  Do not delete the allergy, instead note the reaction or false report in the event that it is reported by the patient again in the future.

 

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In this review of 4 RCTs, when compared with intranasal fentanyl, intranasal ketamine was non-inferior in its efficacy at providing analgesia for acute pain. In total, the studies included 276 participants, aged 3-17, who rated their pain moderate to severe. The patients were randomized to receive either IN ketamine (1-1.5 mg/kg) or IN fentanyl (1.5-2 ug/kg). Most patients had extremity injuries although some also had acute abdominal pain. All studies included patients who had received acetaminophen or ibuprofen prior to the interventions.
 
The reduction in pain at different time points, duration of pain control, and rates of requiring rescue analgesia were similar between the two groups. The risk of adverse events was higher in the ketamine group, however most adverse effects were very minor (nausea/vomiting, dizziness, unpleasant taste, and drowsiness were most frequent). The only serious adverse event (hypotension) was seen in the fentanyl group. Ketamine did have a slightly higher rate of associated sedation, although no patients became deeply sedated after receiving the ketamine and none required any intervention for sedation.
 
Take Home: Intranasal ketamine may be a good non-opioid pain medication to add to your toolkit. Dosing is 1-1.5 mg/kg intranasally. Although there may be an increased risk of adverse events, there are predominantly very minor.

 

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What is the cause of Mad honey poisoning?

 

 

 

 

Grayanotoxin

 

Grayanotoxin is a neurotoxin that is found in honey contaminated with nectar of Rhododendron plants. It binds to activated/open neuronal sodium channels and prevents inactivation of sodium channels. Case reports of mad honey poisoning is often reported in the eastern Black Sea region of Turkey. Commercial honey producers frequently mix honeys from multiple sources to decrease the grayanotoxin contamination.

 

Mad honey poisoning is rarely fatal and generally resolves within 24 hours. Commonly reported symptoms include dizziness, weakness, impaired consciousness/disorientation, excessive perspiration, nausea/vomiting, and paresthesia. In severe intoxication, patients can experience complete AV block, bradycardia/asystole, hypotension, and syncope. 

 

Management is primarily supportive with atropine and IV fluids.


Category: Critical Care

Title: Supraglottic airways to prevent aerosol spread during chest compressions in the COVID-19 era.

Keywords: airway management, cardiac arrest, COVID-10, SARS-CoV-2, cardiopulmonary resuscitation, CPR (PubMed Search)

Posted: 11/3/2020 by Kami Windsor, MD
Click here to contact Kami Windsor, MD

 

As the number of COVID-19 cases rises worldwide, prehospital and emergency department healthcare workers remain at high risk of exposure and infection during CPR for patients with cardiac arrest and potential SARS-CoV-2. 

Existing evidence supports similar cardiac arrest outcomes in airways managed with a supraglottic airway (SGA) compared to endotracheal intubation (ETT).1  It is generally accepted that the best airway seal is provided with endotracheal intubation + viral filter, but how well do SGAs prevent spread of aerosols? 

In CPR simulation studies:

  • Cuffed endotracheal tube + viral filter provides effective seal to prevent aerosolization during CPR.2
  • SGA + viral filter decreases AP spread compared to facemask and compared to bag-valve mask ventilation during CPR.3
  • Notable aerosolization is seen with SGAs, with no difference between AuraGain, I-gel, LMA Proseal, LMA Supreme, Combitube, or LTS-D.2
 
Bottom Line: 
  • Ventilating through an SGA + viral filter is likely better to limit spread of aerosolized particles than bag-valve mask ventilation.
  • SGAs allow egress of aerosolized particles, although the amount and area of distribution in clinical practice is unclear, and endotracheal intubation with a cuffed endotracheal tube remains the best way to avoid ongoing aerosolized particle spread with chest compressions. 
  • Appropriate PPE remains crucial to limiting healthcare workers' risk of infection and must be prioritized, even/especially in the management of patients in cardiac arrest. 

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The current COVID-19 pandemic and known aerosolized transmission has triggered many ED process changes, including the discouragement of utilizing nebulizers to administer inhaled bronchodilators such as albuterol for concern of spread. Historically, both patients and providers preferred the use of nebulizers as they are easier to use and the belief was that they were more effective than meterd dose inhalers. However, evidence based data has consistently shown that for both adult and pediatric patients that when MDI's are used WITH a spacer:

  • There is NO significant difference in efficacy outcome.
  • Nebs are associated with greater increase in tachycardia and tremors.
  • Nebs are more costly overall.
  • MDI's were associated with shorter ED stays and fewer hospital admissions for pediatric patients.

Albuterol:  2.5 mg nebulizer solution = 3-5 MDI puffs

Albuterol: 5 mg nebulizer solution = 5-10 MDI puffs

Ipratropium: 0.25 mg nebulizer solution = 2 MDI puffs

Ipratropium: 0.5 mg nebulizer solution = 4 MDI puffs

 

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Category: Toxicology

Title: What's in that unlabeled container?

Keywords: chemical transfer, unlabeled bottle, poison center (PubMed Search)

Posted: 10/29/2020 by Hong Kim, MD, MPH
Click here to contact Hong Kim, MD, MPH

 

Transfer of chemical from their original container to an unlabeled or different container (e.g. Gatorade bottle) is one of the common causes of unintentional poisoning. 

A retrospective study of National Poison Data System from 2007 – 2017 identified 45,512 cases of unintentional exposure/ingestion of chemicals contained in unlabeled/incorrectly labeled containers. 

 

Result

Annual reported cases increased from 3,223 in 2007 to 5,417 in 2017.

  • Median age: 30 years (interquartile range: 6 – 53)
  • Female: 52%

Most commonly involved products included

  • Cleaning products: 38.2%
    • Bleach, 18.8%
    • Peroxides, 5.7%
    • Anionic cleaners, 4.6%
  • Disinfectants: 17.3%
  • Hydrocarbons: 5.0%

These exposures led to 

  • ED visits: 9,369 (20.6%) 
  • Hospitalization: 1,856 (4.1%) 
  • Deaths: 23 (0.1%)

The majority of these exposures were non-toxic in nature (72%) but serious outcomes were noted in 4.4% of the cases, including 23 deaths.

Highest morbidity was associated with:

  • Pesticides: 10.3%
  • Prescription medications: 9.8%
  • Herbicides: 7.6%

Deaths

  • Hydrofluoric acid and herbicides accounted for 13 of 23 deaths (57%), followed by cleaning products (7/23).

 

Conclusion

  • Transfer of a chemical to unlabeled/different container is a well-recognized risk factor of poisoning.
  • Although small in number, the annual reported cases to the regional poison center are increasing.

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Category: Orthopedics

Title: Ulnar Collateral ligament injuries of the elbow

Keywords: Elbow, dislocation, instability (PubMed Search)

Posted: 10/25/2020 by Brian Corwell, MD (Updated: 12/4/2020)
Click here to contact Brian Corwell, MD

Ulnar Collateral ligament injuries of the elbow

 

Overhead throwing athletes are at risk of insufficiency and rupture of the ulnar collateral ligament (UCL) of the elbow

This can lead to valgus instability similar to what can occur in the knee

Overhead throwing places a significant valgus stress on the elbow

Though classically seen in baseball pitchers, may also be seen in javelin throwers and other high velocity throwing sports

In the acute setting may be seen after an elbow dislocation

History includes a “pop” and medial elbow pain following throwing activities

In cases of overuse injury, athletes will report a progressive loss of velocity, accuracy, and/or endurance with throwing.

The ulnar collateral ligament is the primary restraint to valgus stress from 30 to 120 degrees of flexion

One classic test for UCL instability is the milking maneuver

Patient may be sitting or standing

Patient’s forearm is supinated and elbow flexed at 90 degrees

A valgus force is applied by pulling the patient’s thumb while the examiner’s other hand stabilizes the elbow and palpates the medial joint line. 

Instability, pain or apprehension at the UCL is considered a positive test

https://www.youtube.com/watch?v=gbn24X_qqn0


Category: Critical Care

Title: Use of N-Acetylcysteine for non-acetaminophen acute liver failure

Keywords: NAC, Liver Failure, n-acetylcysteine (PubMed Search)

Posted: 10/20/2020 by Mark Sutherland, MD (Updated: 12/4/2020)
Click here to contact Mark Sutherland, MD

N-acetylcysteine (NAC) is well known as the accepted antidote for acute acetaminophen (tylenol/paracetamol) overdose and is well studied for this indication.  While the literature base is not nearly as strong in other causes of acute liver failure, NAC is increasingly used in these scenarios as well.  In the emergency department in particular, the cause of fulminant hepatic failure is often not known.  NAC may have some protective benefit in non-acetaminophen acute liver failure.  Existing data do not show a mortality benefit to NAC in non-acetaminophen acute liver failure, but do show improvement in transplant-free survival.  The AASLD guidelines (last revised in 2011) do not comment on NAC in non-acetaminophen acute liver failure.  A common practice is to continue NAC until the INR is < 2 and AST/ALT have decreased at least 25% from their peak values.  

Patients in fulminant liver failure should also be strongly considered for transfer to a center that does liver transplant, if presenting to a non-transplant center.  The King's College criteria is the most commonly used prognostic score for determining need of transfer to a transplant center, but in addition to calculating a King's College score providers should generally consider consultation with a transplant hepatologist for any fulminant liver failure patient to discuss the risks/benefits of transfer for transplant evaluation.

 

Bottom Line: While not as strongly indicated as it is in acute acetaminophen induced liver failure, NAC should be considered in both non-acetaminophen liver failure and liver failure of unknown etiology.  In addition, strongly consider consultation with a transplant hepatologist in any case of fulminant hepatic failure.

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Category: Pediatrics

Title: Labial adhesions

Keywords: GU anomaly, prepubescent (PubMed Search)

Posted: 10/16/2020 by Jenny Guyther, MD
Click here to contact Jenny Guyther, MD

A labial adhesion is defined as a thin avascular clear plane, a raphe, between the labia minora. These adhesions which can be caused by minor trauma or infection in the absence of estrogen  can cause varying degrees of obstruction.  

The prevalence is between 0.6% and 5% of females and occurs between 3 months and 3 years of age with a peak between 13 and 23 months.  At least 50% are asymptomatic and found incidentally.  Patient may also have a UTI (20%), postvoid dripping (13%), urinary frequency (7%), or vaginitis (9%).  First-line treatment: estradiol cream 0.01% 1-2x/day for 2-6 weeks. Gentle traction during application of the cream increases the success of separation.  The success rate is between 50% and 89%.  Apply an emollient to reduce recurrence rate.  If there are severe symptoms or medical therapy fails, surgical separation is recommended.

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Category: Toxicology

Title: Co-ingestion of dihydropyridine with ARBs/ACEIs can cause more significant hypotension

Keywords: dihydropyridine, ARBs, ACEIs, co-ingestion, hypotension, toxicity (PubMed Search)

Posted: 10/15/2020 by Hong Kim, MD, MPH
Click here to contact Hong Kim, MD, MPH

 

Dihydropyridine (calcium channel blocker) overdose is one of the leading causes of death from cardiovascular drug poisoning. In contrast, angiotensin-II receptors blockers (ARBs) and angiotensin converting enzyme inhibitor (ACEIs) causes minimal toxicity in overdose. Frequently, these medications are co-ingested with dihydropridines. 

Recently, a retrospective study was conducted to evaluate the hemodynamic impact of  dihydropyridines with ARBs/ACEIs co-ingestion.

Results

Cohort

  • 68 mixed overdoses of dihydropyridines with ARBs/ACEIs
  • 21 single agent overdose (dihydropyridines)

Mixed overdose group had:

  • Lower median nadir mean arterial pressure: 62 vs. 75 mmHg (p<0.001)
  • Higher OR for hypotension: OR 4.5, (95% CI: 1.7 – 11.9)
  • Higher OR for bradycardia: OR 8.8 (95% CI: 1.1 – 70) 
  • Lower minimum systolic blood pressure by 11.5 mmHg (95% CI: 4.9 – 18.1)

Higher proportion of the mixed overdose group received:

  • IV fluids: OR 5.7, (95% CI: 1.8-18.6)
  • Antidotes and/or vasopressor: OR 2.9 (95% CI: 1.004 – 8.6)

Conclusion

Combined overdose of dihydropyridines with ARBs/ACEIs can result in more significant hypotension.

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  • When dealing with weakness and sensory complaints in the ED, the time course of symptoms and physical exam findings help identify emergent conditions.
  • We often talk about upper motor neuron vs. lower motor neuron signs that distinguish whether a lesion is in the central or peripheral nervous system.
  • Characteristics that differentiate between central vs. peripheral nervous system pathology include:
  Central Nervous System Peripheral Nervous System
Pattern of Symptoms
Hemibody involvement
Weakness of UE extensors
Weakness of LE flexors
Distal involvement in polyneuropathy
Distal and proximal involvement in polyradiculoneuropathy
Proximal involvement in polyradiculopathy
Sensory often precedes motor symptoms 
Pure proximal>distal weakness may be due to myopathy or NMJ disorder
Sensory Symptoms
• Central poststroke pain (hyperalgesia, allodynia)
• Sensory level in spinal cord pathology 
• Proprioception involved early in dorsal column disorders
Neuropathic pain (burning, tingling, shock-like) 
Ascending sensory loss involving distal BLE>BUE in polyneuropathy
Proprioception involved late in polyneuropathy
Reflexes
Hyperreflexia in affected limb(s) after acute period
Positive Babinski’s sign
Hyporeflexia in affected limb(s)
Tone Increased after acute period Decreased
UE = upper extremity
LE = lower extremity
NMJ = neuromuscular junction
 
Bottom Line: A systematic approach to the evaluation of weakness and sensory complaints in the ED help differentiate between central vs. peripheral nervous system pathology.

 

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Blood Pressure Management in Acute Ischemic Stroke

  • Blood pressure (BP) is elevated in many patients who present to the ED with an acute ischemic stroke (AIS).
  • Severe elevations in BP are associated with hemorrhagic transformation, as well as cardiac and renal complications.
  • As such, it is important to know the various BP goals for patients with an AIS.
    • Permissive hypertension with a BP less than or equal 220/120 mm Hg is recommended for patients not receiving IV-tPA or endovascular therapy.
    • BP should be lowered to less than or equal to 180/105 mm Hg for patients who have received IV-tPA.
    • BP goals for patients who have received endovascular therapy remain controversial and should be individualized based on the degree of recanalization.

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Category: Orthopedics

Title: Carpal Tunnel Syndrome

Keywords: Carpal Tunnel Syndrome, neuropathy (PubMed Search)

Posted: 10/10/2020 by Brian Corwell, MD (Updated: 12/4/2020)
Click here to contact Brian Corwell, MD

Carpal Tunnel Syndrome (CTS)

 

The hallmark of classic CTS:  pain or paresthesia (numbness and tingling) in a distribution that includes the median nerve territory, with involvement of the first three digits and the radial half of the fourth digit.

The symptoms of CTS are typically worse at night and often awaken patients from sleep.

Fixed sensory loss is usually a late finding

Involves the median-innervated fingers BUT spares the thenar eminence.

This pattern occurs because the palmar sensory cutaneous nerve arises proximal to the wrist and passes over, rather than through, the carpal tunnel.

Consider a more proximal lesion in cases involving sensory loss in the thenar eminence

            Example: pronator syndrome