UMEM Educational Pearls

Category: Orthopedics

Title: Lisfranc Fracture

Keywords: Lisfranc Fracture (PubMed Search)

Posted: 4/29/2017 by Michael Bond, MD (Updated: 4/30/2017)
Click here to contact Michael Bond, MD

Takeaways

Lisfranc Fracture: Typically consists of a fracture of the base of the second metatarsal and dislocation, though it can also be associated with fractures of a cuboid.

Pearls:
  • Fracture findings on plain films may be subtle.
  • If in doubt obtain weight bearing AP views of the foot to demonstrate dislocation/fracture.
  • If weight bearing films are negative and you are still suspicious consider a CT scan of the foot.

Click below see image of fracture

Show More In-Depth Information


Takeaways

The FDA recently announced restrictions on the use of Tramadol and Codeine in children and breastfeeding mothers due to possible harm in infants.  Essentially, codeine will now be contraindicated for the treatment of cough and/or pain, and tramadol contraindicated to treat pain for children under age 12 years. Tramadol will be also be contraindicated in children younger than 18 years for treatment of pain after tonssillectomy/ adenoidectomy. 
 
These medicines carry serious risks, including slowed or difficulty breathing and death. These medicines also should be limited in some older children.
 
Additional warnings apply for children 12 to 18 years who are obese, have severe lung disease, or sleep apnea as they may increase the risk of serious breathing problems. 
 
Please be aware of these new restrictions to protect the health and safety of our patients.
 
A summary statement from the American Hospital Association (AHA) is posted below.

Bottom line: Do not prescribe codeine or tramadol for cough or pain in children and breastfeeding moms.

Show More In-Depth Information


Category: Toxicology

Title: "Triple C" Overdose

Keywords: Dextromethorphan, Robotripping (PubMed Search)

Posted: 4/20/2017 by Kathy Prybys, DO (Emailed: 4/27/2017)
Click here to contact Kathy Prybys, DO

Takeaways

A 17 y/o male presented for altered mental status. His mother stated she was contacted by neighbor concerned that her son was wandering down the middle of a local roadway. His friends stated he had taken 16-17 "triple C's" in an attempt to "get high". No other coingestants were identified. At presentation, the patient appeared to be in an toxic delirium. VS : 187/112, 116, 16, 98.9, 100% RA. Patient  was awake with eyes open but slowly responsive.GCS was 12. No evidence for trauma. Pupils were dilated and slowly reactive. The rest of the exam was essentially negative.
 
  • Coricidin Cough & Cold medicine also known by street name 'Triple C" is the most commonly reported abused dextromethorphan-containing product.
  • Dextromethorphan at high doses acts as a dissociative general anesthetic and hallucinogen similar to Ketamine and Phencyclidine (PCP) by antagonizing the NMDA receptor in a dose dependent manner.
  • Detromethorphan-containing products are appealing to teens as they are easily available (OTC), legal, inexpensive, and preceived as safe. 
  • Street names for dextromethorphan products include DXM, CCC, Trile C, Skittles, Robo, Poor Man's PCP,. Abuse of Robitussin products is referred to as "Robotripping"
  • Additional toxicity can occur from the coingredients (pseudoephedrine, acetaminophen, and antihistamines such as Chlorpheniramine) is a serious concern of taking large amounts of OTC cough and cold medications for the Dextromethorphan content. Chlorpheneriamine is a  first generation H1-histamine receptor antagonist with potent antimuscarinic properties.
  • Dextromethorphan is not detected by basic drug screens and should be considered when evaluating patients with a dissociative toxidrome. Acetaminophen levels should be obtained.
  • No specific antidote exists for dextromethorphan toxicity. Benzodiazepines should be administered for seizures and aggressive cooling measures for hyperthermia. Naloxone can be considered for use in patients in a coma or with respiratory depression but variable results are reported.
 

Show More In-Depth Information

Show References


Takeaways

Haloperidol has a higher D2 receptor antagonist effect than standard antiemetic treatment agents such as metoclopramide. In addition, newer antipsychotic agents such as Olanzapine have a high affinity at multiple antiemetic sites such as the dopamine and serotinergic receptors.

While formal RCT's are still in the works, multiple sources including palliative care, emergency medicine, and pain journals support their use in refractory emesis.


Consider Haloperidol 3-5 mg IV. 
Check an EKG for long QTc prior to use. Consider dose reduction of haloperidol in those with hepatic impairment. Also consider dose reduction in patients taking carbamazepine, phenytoin, phenobarbital, rifampicin, or quinidine due to that pesky CYP3A4 inhibition. 

Consider Olanzapine 2-5 mg IV.

Several case reports have shown a higher rate of success with olanzapine for refractory emesis. Olanzapine has similar precautions as those to haloperidol (EKG, hepatic impairment), although it's CYP drug interactions are less common. Additionally, use olanzapine cautiously in hyperglycemic patients as there are several case reports of olanzapine prompting episodes of DKA. Consider frequent blood sugar checks or small doses of insulin in hyperglycemic patients. 

 

Take Home Points:

Consider the antipsychotic agents Haloperidol or Olanzapine for patients with refractory emesis, they may be more effective than traditional antiemetics. 

Get an EKG prior to administration to check for QTc prolongation. As the classical and atypical antipsychotic agents are sedating, use caution in conjunction with other sedating medications (such as benzodiazepines).  

 

Show More In-Depth Information

Show References


Category: Neurology

Title: Vasogenic Cerebral Edema

Keywords: vasogenic cerebral edema, white matter, blood-brain-barrier, steroids (PubMed Search)

Posted: 4/26/2017 by WanTsu Wendy Chang, MD
Click here to contact WanTsu Wendy Chang, MD

 
Vasogenic Cerebral Edema
  • Vasogenic cerebral edema is most commonly seen with brain tumors and cerebral abscesses.
  • It mainly involves the white matter.
  • Gray-white differentiation is maintained, so the edema has a finger-like pattern on CT (see Figure).
  • It is caused by disruption of the blood-brain-barrier, thus responds to treatment with steroids.

 

Show References


Attachments

20170426_Figure.jpg (60 Kb)


Ventilator Settings for the Post-Arrest Patient

  • The majority of patients with ROSC from OHCA require intubation and mechanical ventilation.
  • Correctly managing the ventilator in the post-arrest patient is critical for improving outcomes.
  • As patients are at high risk for ARDS, use lung-protective ventilation with tidal volumes between 6 to 8 ml/kg of ideal body weight and PEEP of 5 to 8 cm H2O.
  • There is a U-shaped relationship between neurologic outcomes and both PaO2 and PaCO2.
    • Target normoxia (SpO2 94% to 96%) and avoid hyperoxia and hypoxia.
    • Target normocapnia (PaCO2 40 to 50 mm Hg) and avoid hypercapnia and hypocapnia.
  • Use an analgosedation approach with short-acting analgesics and sedatives, such as fentanyl and propofol.

Show References


Category: Orthopedics

Title: Septic Arthritis in Children

Keywords: Hip, pediatrics, arthritis (PubMed Search)

Posted: 4/22/2017 by Brian Corwell, MD (Updated: 5/1/2017)
Click here to contact Brian Corwell, MD

Septic Arthritis in Children

Classic presentation: Pain, fever (may not always be present)

Limited range of motion of joint or refusal to bear weight,

 Joint swelling (difficult to visualize in hip or shoulder),

Limb held in position that allows greatest capsular volume (elbow held in 30° flexion for example)

Diagnostic testing may include diagnostic markers (ESR, CRP) or imaging (US/MRI)

Most common organisms: Staph and Strep, Neisseria (adolescents), HACEK organisms, consider gram negatives in immunocompromised children

DDX: Transient synovitis, osteonercrosis or osteomyelitis, Psoas abscess, acute leukemia, Lyme disease

A common ED presentation is the child with the painful limp

               35% of all cases of septic arthritis

>50% of cases occur in children younger than 2yo

Hip held in flexion, Abduction, external rotation

Fever and inflammatory markers are more sensitive than WBC count and refusal to bear weight

Kocher criteria:

1)     Refusal to weight bear on affected side

2)     Sed rate greater than 40mm/hr

3)     Fever (>38.5°C

4)     WBC count of >12,000 mm3

 

IF
                 - 4/4 criteria are met, there is a 99.6% chance of septic arthritis; 
                 - when 3/4 criteria are met, there is a 93% chance of septic arthritis; 
                 - when 2/4 criteria are met, there is a 40% chance of septic arthritis; 
                 - when 1/4 criteria are met, there is a 3% chance of septic arthritis; 

 

CRP can also be incorporated into a diagnostic algorithm

CRP>2.0 (mg/dl) in a child who refuses to bear weight yields a 74% probability of septic arthritis

 

 

Show References


Takeaways

Predictive factors of asthma development in patients diagnosed with bronchiolitis include:

- Male sex (OR 1.3)

- Family history of asthma (OR 1.6)

- Age greater than 5 months at the time of bronchiolitis diagnosis (OR 1.4)

- More than 2 episodes of bronchiolitis (OR 2.4)

- Allergies (OR 1.6)

Show More In-Depth Information

Show References


Category: Toxicology

Title: Drug induced lactic acidosis.

Keywords: lactic acidosis (PubMed Search)

Posted: 4/20/2017 by Hong Kim, MD, MPH (Updated: 5/1/2017)
Click here to contact Hong Kim, MD, MPH

Lactic acids are often elevated in critical care patients (e.g. septic shock). It can be also elevated in setting of drug overdose or less frequently in therapeutic use due to interference of oxidative phosphorylation. Some of the agents include:

 

  • Carbon monoxide
  • Cyanide
  • Propofol
  • Metformin
  • Propylene glycol
  • Salicylates
  • Beta-2 agonists
  • Thiamine deficiency/alcoholic ketoacidosis
  • Ethylene glycol/toxic alcohols
  • Nucleoside reverse-transcriptase inhibitors

 

Bottom line:

  • Although elevated lactic acid levels are often associated with underlying medical conditions, it is important to recognize drug-induced etiologies of lactic acidosis. 

Show References


Category: International EM

Title: Reduced Shigella Susceptibility to Ciprofloxacin

Keywords: CDC, Shigella, antibiotic, health advisory (PubMed Search)

Posted: 4/19/2017 by Jon Mark Hirshon, MD, MPH (Updated: 5/1/2017)
Click here to contact Jon Mark Hirshon, MD, MPH

Takeaways

The Centers for Disease Control and Prevention (CDC) just released an official health advisory through the Health Alert Network entitled: “CDC Recommendations for Diagnosing and Managing Shigella Strains with Possible Reduced Susceptibility to Ciprofloxacin”

 

Concerning treatment, one key point is:

Do not routinely prescribe antibiotic therapy for Shigella infection. Instead, reserve antibiotic therapy for patients for whom it is clinically indicated or when public health officials advise treatment in an outbreak setting.

o   Shigellosis is generally a self-limited infection lasting 5-7 days.

o   Unnecessary treatment with antibiotics promotes resistance.

o   Treatment can shorten the duration of some illnesses, though typically only by 1-2 days

Show More In-Depth Information

Show References


Category: Critical Care

Title: Use Ultrasound to confirm CVC placement

Keywords: Central venous catheter, ultrasound (PubMed Search)

Posted: 4/18/2017 by Kami Hu, MD (Updated: 5/1/2017)
Click here to contact Kami Hu, MD

Takeaways

Save time by using bedside ultrasound to confirm above-the-diaphragm central venous catheter (CVC) placement rather than waiting for chest x-ray confirmation:

1. Perform rapid push of saline (it doesn’t have to be agitated) through CVC while cardiac probe is placed with right atrium in view. Immediate visualization of bubbles (or “atrial swirl”) essentially confirms correct placement.

2. Perform the usual search for ipsilateral lung-sliding and the waves-on-the-beach to rule out procedural pneumothorax.

 

 

Show More In-Depth Information

Show References


Question

A 50 years old male with a history of CHF, presenting to the ED with progressively worsening shortness of breath. POCUS was performed. The picture shows the left lower part of the chest. What is the diagnosis?

Show Answer

Show References


Category: Orthopedics

Title: Does spinal manipulation work for back pain

Keywords: back pain, manipulation (PubMed Search)

Posted: 4/15/2017 by Michael Bond, MD (Updated: 5/1/2017)
Click here to contact Michael Bond, MD

We all wish there was a great treatment regimen for our patients with back pain. However, most studies have shown that it really does not matter what you do, as most patients will get better in 6 weeks.

A recent study published in JAMA looked at the role of spinal manipulation to improve pain and function in adults with low back pain. They looked at 26 randomized controlled trails and found that there was modest benefit for spinal manipulation and it was similar to using NSAIDs.

So spinal manipulation may or may not work for some patients. Something to consider along with physical therapy if patients are not getting relief with home remedies.

 

Show References


Category: Pediatrics

Title: Does urine concentration effect the diagnosis of urinary tract infection?

Keywords: Pediatrics, urinary tract infection, urine concentration (PubMed Search)

Posted: 4/14/2017 by Jenny Guyther, MD (Updated: 5/1/2017)
Click here to contact Jenny Guyther, MD

Takeaways

A recent study suggests that using a lower cut off value of white blood cells in dilute urine, may have a higher likelihood of detecting a urinary tract infection in children.

In dilute urine (specific gravity < 1.015), the optimal white blood cell cut off point was 3 WBC/hpf (Positive LR 9.9).  With higher specific gravities, the optimal cut off was 6 WBC/hpf (Positive LR 10).  Positive leukocyte esterase has a high likelihood ratio regardless of the urine concentration. 

 

Show More In-Depth Information


Category: Neurology

Title: Simplified GCS vs. Full GCS? Which One To Use?

Keywords: Glasgow Coma Scale, GCS, motor GCS, mGCS, Simplified Motor Scale, SMS (PubMed Search)

Posted: 4/12/2017 by WanTsu Wendy Chang, MD
Click here to contact WanTsu Wendy Chang, MD

 
Simplified GCS vs. Full GCS?  Which One To Use?

  • The Glasgow Coma Scale (GCS) is an instrument widely used to assess level of consciousness by EMS.
  • The motor GCS (mGCS) and Simplified Motor Scale (SMS) have been proposed to simplify EMS triage.
  • A number of retrospective studies have compared these scales.
  • Chou et al. performed a systematic review and meta-analysis of 18 studies with a total number of 1.7 million patients to compare the predictive utility of these scales for identification of patients with severe traumatic injury.
  • The total GCS was slightly better than the mGCS or SMS on predicting mortality, neurosurgical intervention, severe traumatic brain injury, and emergent intubation.

Bottom Line:  The motor GCS and Simplified Motor Scale (SMS) have similar discrimination when compared with the total GCS, and may be easier to use.

Show References


Category: Critical Care

Title: Avoiding Hyperoxia in Patients on Mechanical Ventilation

Keywords: Hyperoxia, Mechanical Ventilation (PubMed Search)

Posted: 4/11/2017 by Rory Spiegel, MD (Updated: 5/1/2017)
Click here to contact Rory Spiegel, MD

The deleterious effects of hyperoxia are becoming more and more apparent. But obtaining a blood gas to ensure normoxia in a busy Emergency Department can be burdensome. And while the utilization of a non-invasive pulse oximeter seems ideal, the threshold that best limits the rate of hyperoxia is unclear.

Durlinger et al in a prospective observational study demonstrated that an oxygen saturation 95% or less effectively limited the number of patients with hyperoxia (PaO2 of greater than 100 mm Hg). Conversely when an SpO2 of 100% was maintained, 84% of the patients demonstrated a PaO2 of greater than 100 mm Hg.

 

Show References


Most of our knowledge of the athlete’s EKG is based on white athletes.

African/Afro-Caribbean athletes are more likely to have an abnormal EKG than white athletes in multiple studies.

Different selective criteria have been developed to minimize classification of benign normal patterns as abnormal.

The 2010 ESC criteria classified 40.4% of black athletes as abnormal versus the Refined criteria which resulted in 11.5% of EKGs classified as abnormal.

This reduction was aided by the recognition that isolated anterior TWI in asymptomatic black athletes is considered a benign finding.

               Note this does NOT apply if the TWI extend to the lateral leads

For example, T-wave inversion (TWI) was present in 23% of African/Afro-Caribbean athletes vs. 3.7% of white athletes (usually in contiguous anterior leads).

Other changes included a higher prevalence of early repolarization, RV hypertrophy, and LA/RA enlargement.

Show References


Category: Toxicology

Title: Sodium bicarbonate shortage Is there an alternate solution?

Keywords: sodium bicarbonate, sodium acetate (PubMed Search)

Posted: 4/6/2017 by Hong Kim, MD, MPH (Updated: 5/1/2017)
Click here to contact Hong Kim, MD, MPH

FDA announced a shortage of sodium bicarbonate on 3/01/17.  Sodium bicarbonate is frequently used in acid-base disorder as well as in poisoning (cardiac toxicity from Na-channel blockade, e.g. TCA & bupropion, and salicylate poisoning).

 

Acetate is a conjugate base of acetic acid where acetate anion forms acetyl CoA and enters Kreb cycle after IV administration. Final metabolic products of acetate are CO2 and H2O, which are in equilibrium with bicarbonate via carbonic anhydrase activity.

 

Administration of sodium acetate increases the strong ion difference by net increase in cations, as acetate is metabolize, and leads to alkalemia.

 

Adverse events from sodium acetate infusion have been associated with its use as dialysate buffer: myocardial depression, hypotension, hypopnea leading to hypoxemia and hyperpyrexia. However, such adverse events have not been reported in toxicologic application.

 

 

Bottom line:

Sodium acetate can be administered safely in place of sodium bicarbonate if sodium bicarbonate is not available due to shortage.

Sodium acetate dose:

  • Bolus: 1 mEq/kg over 15 – 20 min
  • Infusion: 150 mEq in 1L D5%W @ twice maintenance rate   

Show References


·       In the elderly, falling is the most common mechanism of injury
·       Unavoidable Risk factors: age 85 or older, male, Caucasian, history of falls
·       Other factors: alcohol consumption, polypharmacy
·       Mechanisms of fall:  slipping, tripping, stumbling
·       Physical exam to include: gait, balance, proprioception, vision, strength and cognitive function testing
·       Must consider neglect/abuse, affects 10% of seniors per year
·       Evaluate for anticoagulant use due to increased risk of intracranial injury
·       Use advanced imaging to identify occult hip fractures when clinically suspected and plain radiographs are negative

 

Show References


Category: Pharmacology & Therapeutics

Title: On your radar: methadone-linezolid drug-drug interaction

Keywords: methadone, linezolid, serotonin syndrome, drug interaction (PubMed Search)

Posted: 4/1/2017 by Michelle Hines, PharmD (Updated: 4/3/2017)
Click here to contact Michelle Hines, PharmD

Linezolid is a weak, nonselective monoamine oxidase inhibitor (MAOI). A recent FDA Drug Safety Communication released in March 2016 noted reports of serotonin syndrome associated with certain opioids, particularly fentanyl and methadone. Development of serotonin syndrome after concomitant administration of linezolid with other serotonergic agents has been reported. Due to a potential risk of serotonin syndrome, a patient on chronic methadone should not be started on concomitant linezolid unless they will be monitored.

Show References