UMEM Educational Pearls

Takeaways

Bottom Line:

  1. The most often cited meta-analysis regarding route of PPI use in bleeding peptic ulcer disease evaluates rebleeding AFTER endoscopic treatment and only ulcers with high-risk features.  There is no good data on optimal pre-endoscopy dosing.
  2. These studies appear to show non-inferiority of intermittent dosing with a trend towards superiority when compared with continuous dosing.
  3. The proper dosing, frequency, and route of intermittent PPI use is widely variable without good data on an optimal regimen.
  4. ED decision of intermittent vs continuous PPI should consider other patient factors including severity of illness, compatibility of IV lines (pantoprazole is often incompatible), and patient disposition.

 

 

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Category: Pediatrics

Title: When do I get a chest xray in a child with asthma?

Keywords: Asthma, chest xray (PubMed Search)

Posted: 7/20/2018 by Jenny Guyther, MD (Updated: 7/22/2018)
Click here to contact Jenny Guyther, MD

Takeaways

Chest xrays (CXRs) may lead to longer length of stay, increased cost, unnecessary radiation exposure, and inappropriate antibiotic use.

CXR in asthma are indicated for:

-severe persistent respiratory distress, room air saturations <91%

- focal findings (localized rales, crackles, decreased breath sounds with or without a documented fever > 38.3) not improving on >11 hours of standard asthma therapy

- concern for pneumomediastinum or pneumothorax

 

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Category: Toxicology

Title: Octreotide use for Sulfonylurea Poisoning

Keywords: Sulfonylureas, Octreotide (PubMed Search)

Posted: 7/19/2018 by Kathy Prybys, DO
Click here to contact Kathy Prybys, DO

Sulfonylureas are commonly used oral hypoglycemic agents for type II diabetes. Agents on the market include glipizide (Glucotrol), glyburide (Micronase, Glynase, Dibeta) and glymepiride (Amaryl). These agents exert their effect by stimulation of insulin release from the pancreatic beta islet cells. Following overdose, hypoglycemia is usually seen within a few hours of ingestion and can be prolonged and profound. First line treatment for rapid correction of severe hypoglycemia is administration of an intravenous bolus of concentrated dextrose. However, use of dextrose infusion in attempt to maintain euglycemia is problematic as it can cause further release of insulin and rebound hypoglycemia. Octreotide ia a long acting synthetic somatostain analogue, blocks insulin secretion and has been shown to prevent recurrence of hypogylcemia better than placebo.

Bottom Line:

  • Octreotide is the antidote of choice for sulfonylurea poisoning. Its use greatly simplifies management by avoiding the need for a central line, prolonged ICU admit, and frequent monitoring.
  • Bolus 50 μg IV followed by an infusion of 25–50μg/h or give100 mcg subcutaneously with additional doses at 6-12 hour intervals for recurrent hypoglycemia. Octreotide has similar bioavailability by SC and IV route. It's duration of action can extend from 6 to 12 hours with SC use.
  • After stopping Octreotide monitor for 12-24 hours for rebound hypoglycemia.

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Category: Critical Care

Title: Noninvasive Ventilation in Do-Not-Intubate Patients

Keywords: noninvasive positive pressure ventilation, NIV, NIPPV, DNI, do-not-intubate, palliative care, end-of-life, respiratory distress (PubMed Search)

Posted: 7/17/2018 by Kami Hu, MD
Click here to contact Kami Hu, MD

When a do-not-intubate (DNI) hospice patient arrives in the ED with respiratory distress, consideration of non-invasive positive pressure ventilation (NIPPV) could invoke either a “What other option do I have?” or “Why torture the patient and prolong the dying process?” sentiment.

 

But what’s the data?

A recently-published meta-analysis1 found that in DNI patients receiving NIPPV, there was a 56% survival rate to hospital discharge and 32% survival to 1-year.

  • Higher survival was seen in patients with COPD and pulmonary edema as the cause of their respiratory failure, as opposed to pneumonia or malignancy.
  • In surviving patients, there was no decrease in quality of life at 3 months; quality of life was not assessed in the time before death in nonsurvivors.
  • In comfort-measures only (CMO) patients, patients receiving NIPPV had a mildly lower dyspnea score with less opiates required/administered.

 

Independent studies have demonstrated:

  • Better survival with NIPPV for DNI COPD and CHF patients2,3,4 who are awake and have a good cough.4
  • No decrease in health-related quality of life or post-ICU psychological burden (symptoms of PTSD, anxiety, or depression) in DNI survivors receiving NIPPV.3
  • 63% survival to hospital discharge & 49% survival to 90 days in DNI patients receiving NIVV, with no decrease in health-related quality of life in survivors. Survival was lower for CMO patients (14% and 0% at discharge and 90 days, respectively).5

 

Bottom Line:

  1. NIPPV can benefit DNI patients -- most identifiably those with COPD or cardiogenic pulmonary edema as the etiology for their respiratory distress.
  2. Mild benefits to dyspnea have been seen in CMO patients, without survival benefit. A trial of NIPPV therapy may be reasonable (especially in COPD or CHF) after frank discussion with the patient and his/her loved ones, with quick cessation if comfort is not achieved and/or more discomfort is caused.

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Category: Orthopedics

Title: Stingers and Burners

Keywords: Cervical spine, neuropraxia (PubMed Search)

Posted: 7/14/2018 by Brian Corwell, MD (Updated: 7/22/2018)
Click here to contact Brian Corwell, MD

Stingers and Burners

Also known as transient brachial plexus neuropraxia, “dead arm syndrome,” or brachial plexopathy. Symptoms such as pain, burning, and/or paresthesias in a single upper limb, lasting seconds to minutes.

Usually involves more than one dermatome

May be associated with weakness.

               -Common in collision sports that involve tackling, such as football.

               -Most common C-spine injury in American Football.  

               -More than 50% of college football players sustain a stinger each year

-Having 1 stinger increases the risk of having another 3 fold

Mechansims: C5, C6 (deltoid,biceps) most commonly involved

-Traction injury due to forcible lateral neck flexion away with downward displacement of arm

-Nerve root compression during combined neck extension and lateral neck flexion

-Direct trauma to the brachial plexus in the supraclavicular fossa

Physical Exam:

-Examine muscle strength in the deltoid, biceps, and infraspinatus muscles

-Check sensation and reflexes in upper extremities

-Check C-spine range of motion and perform Spurling’s Test

Imaging:

Consider MRI for symptoms lasting more than 24 hours, bilateral symptoms or for recurrent stingers

Return to play guidelines vary:

-No neurologic symptoms

-Can return to play in same game if symptoms resolve within 15 minutes and no prior stingers that season.

-If 2nd stinger in that season, do NOT return to play in the same game

-if 3rd stinger in a season, consider imaging before return to play and consider sitting out the remainder of the season.

 


Category: Pediatrics

Title: Abdominal Migraine: Finding a needle in a haystack

Keywords: Pediatrics, Migraine, Abdominal Migraine, Headache (PubMed Search)

Posted: 7/13/2018 by Megan Cobb, MD
Click here to contact Megan Cobb, MD

Abdominal pain in children can be just as frustrating as dizzy in the elderly. Your exam is targeted at quickly ruling out acute pathologies, but then what? The diagnosis is often  functional gastrointestinal disorders, like the ever exciting constipation. Abdominal migraine (AM) is an additional entity to consider during your emergency department evaluation.

 

The following factors are often associated with AM: 

- peak incidence at 7 years old

- paroxsymal, periumbilical abdominal pain lasting more than 1 hour

- family history of migraine

- episodes not otherwise explained by known pathology. 

AM can be associated with headache, pallor, anorexia, photophobia, and fatigue. There are multiple theories on the pathogenesis, which can be found in the article cited below. If there is a known history, and the patient is presenting with an exacerbation, the treatment protocols for migraine headache may be employed with good success. 

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Bottom Line:

AM is increasingly recognized as a source of recurrent abdominal pain in children. If other organic pathologies can be ruled out, this may be an important diagnosis to consider so your patient can get the appropriate follow up and outpatient management. 

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Category: Toxicology

Title: Utility of physostigmine in antimuscarinic delirium

Keywords: antimuscarinic/anticholinergic toxicity, reversal of delirium (PubMed Search)

Posted: 7/12/2018 by Hong Kim, MD, MPH
Click here to contact Hong Kim, MD, MPH

From 1960s to 1970s, physostigmine was routinely administered as part of the "coma cocktail." Since the publication of two cases by Pentel (1980) that resulted in asystole after administration of physostigmine in TCA poisoned patient, its use has declined significantly.

However, physostigmine still possess limited but clinically useful role in the management of patients with antimuscarinic/anticholinergic induced delirium.

Recently, a prospective observational study was performed in the use of physostigmine when recommended by a regional poison center.

In 1 year study period, physostigmine was recommended by a regional poison center in 125 of 154 patients with suspected antimuscarinic/anticholinergic toxicity. 

common exposures were

  1. antihistamines (68%)
  2. analgesics (19%)
  3. antipsychotics (19%)

57 of 125 patients received physostigmine per treating team.

  • median dose of physostigmine administered: 2 mg

Of the remaining patients,

  • 35 patients did not receive any sedative agents
  • 55 received benzodiazepines (56%)
  • others received propofol (n=10), haloperidol (n=8), olanzapine (n=4), dexmedetomidine (n=3), etc.

Delirium control

  • Physostigmine group 79% (45 of 57)
  • No-physostigmine group: 36% (35 of 97)

Adverse events (physostigmine group vs. non-physo group) - no statistically significant difference.

  • Intubation (n=7): 2 (3.5%) vs. 5 (5.2%)
  • physical restraints (n=10): 3 (5.3%) vs. 7 (7.2%)
  • vomiting (n=4): 3 (5.3%) vs. 1 (1.0%)

Conclusion:

Physostigmine can safely control antimuscarinic/anticholinergic-induced delirium.

 

 

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Legionella is an important cause of community-acquired pneumonia. It ranks among the three most common causes of severe CAP leading to ICU admission and carries a high mortality rate – up to 33%. Resulting from inhalation of aerosols containing Legionella species and subsequent lung infection, it is often associated with contaminated air conditioning systems, and other hot and cold water systems.

 

Recommended antibiotic regimens include a fluoroquinolone, either in monotherapy or combined with a macrolide (typically Levaquin or Azithromycin).

 

A retrospective, observational study published in the Journal of Antimicrobial Chemotherapy in 2017 looked at 211 patients admitted to the ICU with confirmed severe legionella pneumonia treated with a fluoroquinolone vs a macrolide and monotherapy vs combination therapy. Combination therapy included fluoroquinolone + macrolide, fluoroquinolone + rifampicin, or macrolide + rifampicin.

 

Of these 211 cases, 146 (69%) developed ARDS and 54 (26%) died in the ICU. Mortality was lower in the fluoroquinolone-based group (21%) than in the non-fluoroquinolone based group (39%), and in the combination therapy group (20%) than in the monotherapy group (34%). In a multivariable analysis, fluoroquinolone-based therapy, but not combination therapy was associated with a reduced risk of mortality (HR 0.41).

 

 

Take Home Points:

-Remember, our usual blanket coverage with vanc + zosyn in the ED does not cover atypicals!

-Consider Levaquin instead of Azithro if there is clinical concern for Legionella PNA

           -hyponatremia, abnormal LFTs may be clues in the appropriate context

 

 

 

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Category: Pharmacology & Therapeutics

Title: New-Onset Diabetes with DKA in Adults

Keywords: Diabetes, DKA (PubMed Search)

Posted: 7/7/2018 by Wesley Oliver (Updated: 7/22/2018)
Click here to contact Wesley Oliver

Takeaways

Pearl submitted by James Leonard, PharmD, Clinical Toxicology Fellow
 
A 54-year-old male 1-year post-renal transplant arrives to the emergency department in diabetic ketoacidosis (DKA). He has no history of diabetes and is not currently taking steroids for immunosuppression. Home medications include tacrolimus, mycophenolate, and hydrochlorothiazide. Is this latent auto-immune diabetes or something else?
 

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Based in part upon Geriatric Emergency Department Guidelines, the American College of Emergency Physicians has initiated a Geriatric Emergency Department Accreditation Program. Emergency departments (EDs) can be accredited at one of three levels- Gold (Level 1), Silver (Level 2) and Bronze (Level 3). There are various aspects upon which and EDs’ level is determined, including nurse and physician staffing and education, appropriate policies and protocols, quality improvement activities, outcome measures, equipment and the physical environment.


  • The rainy East coast spring has increased tick populations in endemic areas such as Maryland resulting in more tick bites.
  • ED visits for known tick bites present acutely, often with parents bringing in the tick to be identified/tested.
  • Routine serologic testing and antibiotic prophylaxis is not recommended after every tick bite.
  • If an attached tick is engorged, identified as I. scapularis, and has been attached for >36 hours, then antibiotic prophylaxis for Lyme can be prescribed if started within 72 hours of tick removal in those patients > 8 years of age
  • Prophylaxis: Single dose of doxycycline 4 mg/kg or 200mg max 
  • If early Lyme Disese is present in the form of the classic rash of Erythema migrans, then treatment is doxycycline, 4 mg/kg or 100mg max BID for patients > 8 years of age or amoxicillin 50 mg/kg per day divided TID with 500 mg max TID in those < 8 years of age for 14 days 
  • Serologic testing is false negative in the first month of testing, and unnecessary in the ED  for acute presentations. 

Category: Neurology

Title: Can my patient with dementia refuse treatment?

Keywords: capacity, dementia, altered mental status, medicolegal, ethics (PubMed Search)

Posted: 6/27/2018 by Danya Khoujah, MBBS
Click here to contact Danya Khoujah, MBBS

Medical decision-making capacity refers to the patient’s ability to make informed decisions regarding their care, and emergency physicians are frequently required to assess whether a patient possess this capacity. Patients with acute or chronic neurological diseases (such as dementia) may lack this capacity, and this should be identified, especially in life-threatening situations. The patient must have the ability to:

  • communicate a consistent choice

  • understand (and express) the risks, benefits, alternatives and consequences

  • appreciate how the information applies to the particular situation

  • reason through the choices to make a decision

There are numerous tools that may help with this assessment, but none has been validated in the ED. Be careful of determining that the patient lacks capacity just because of the diagnosis they carry. 

 

BONUS PEARLS:

 

 

  • Capacity is a fluid concept; a patient may have the capacity to make simple decisions but not more complex ones. Capacity may also change over time

  •  

  •  

  • Psychiatry consultation to determine capacity is not obligatory but may be utilized for a second opinion.  

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Volume Responsiveness, Carotid Ultrasound, and the PLR

  • Passive Leg Raise (PLR) is accomplished by starting with the patient at a 45’ semi recumbent position, lowering the body to horizontal, passively raising the patients legs to 45’ for 30-90 seconds, then returning the patient to the semi-recumbent position.
  • To assess volume responsiveness using PLR, you must assess cardiac output (CO) and not simply look at the changes in blood pressure or heart rate.
  • Previous papers have shown EtCO2 to be a reasonable surrogate of CO with PLR when ventilation is unchanged.
  • Another option for measuring CO is carotid ultrasound. One study demonstrated good correlation between carotid ultrasound and invasive measurements on ICU patients.  It is calculated using the equation Diameter * VTi, where VTI is the velocity time integral.
  • Take Home Point - Be sure to measure CO with a PLR to help determine volume responsiveness- EtCO2 or carotid ultrasound can be considered as surrogates of CO.

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ED visits for acute gout increased almost 27% between 2006 & 2014, a 26.8% increase

Presentation: Acute severe pain, swelling, redness, warmth.

Pain peaks between 12 to 24 hours and onset more likely at night

Quiet, calm period between flares vs other arthritic disorders

Signs of inflammation can extend beyond the joint

Normal to low serum urate values have been noted in 12 to 43% of patients with gout flares 

Accurate time for assessment of serum urate is greater than 2 weeks after flare subsides

Most hyperuricemic individuals never experience a clinical event resulting from urate crystal deposition.

Gout flares may occasionally coexist with another type of joint disease (septic joint, psedugout),

A clinical decision rule has shown to be more accurate than clinical diagnosis (17 versus 36%)

*Male sex (2 points)

*Previous patient-reported arthritis flare (2 points)

*Onset within one day (0.5 points)

*Joint redness (1 point)

*First metatarsal phalangeal joint involvement (2.5 points)

*Hypertension or at least one cardiovascular disease (1.5 points)

*Serum urate level greater than 5.88 mg/dL (3.5 points)

 Scoring for low (≤4 points), intermediate (>4 to <8 points), and high (≥8 points) probability of gout identified groups with a prevalence of gout of 2.2, 31.2, and 82.5 percent, respectively.

Consider supplementing your clinical decision with this in the future

 

 

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Children with diabetic ketoacidosis (DKA) may have brain injuries ranging from mild to severe. The debate over the contribution from intravenous fluids towards poor neurologic outcomes has been ongoing for decades. 

PECARN's large multicenter randomized, controlled trial examined the effects of the rate of administration and the sodium chloride content of intravenous fluids on neurologic outcomes in children with diabetic ketoacidosis may finally put the controversy to rest. There was no difference on significant neurologic outcomes based on the rate (fast vs slow) or concentration (0.9% vs 0.45%) of IV fluid administration.

Clinically apparent brain injury occurred in 12 of 1389 episodes (0.9%) of children in DKA.

Any change in the mental or neurological status of the patient should be concerning for life threatening edema and should be treated with mannitol 1g/kg IV bolus or hypertonic saline (3%) 5-10 mL/kg IV over 30 minutes.

BOTTOM LINE:

"Neither the rate of administration nor the sodium chloride content of intravenous fluids significantly influenced neurologic outcomes in children with diabetic ketoacidosis"

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Although not specifically a part of current recommendations due to lack of data, the AHA has previously recommended shifting upward on the sternum during CPR in the pulseless pregnant patient in order to account for upward displacement of the heart by a gravid uterus. Should the same be done for our obese patients?

Lee et al. performed a retrospective study that reviewed chest CTs to determine the location on the sternum that corresponded to the optimal point of maximal left ventricular diameter (OPLV), in both obese and non-obese patients. 

They found that the OPLV was higher (more cranial) on the sternum for obese patients than for patients with normal weight, although 96% of obese patients' OPLV fell within 2cm of where the guidelines recommend standard hand placement should be, compared to a notable 52% in non-obese patients.

*as measured from the distal end of the sternum

 

Bottom Line: Radiographically, the location on the sternum that corresponds to optimal compression of the LV is more cranial in obese patients than in non-obese patients. It remains to be seen whether the recommendations for hand placement in CPR should be adjusted, but we may want to consider staying within 4cm of the bottom of the sternum in patients of normal weight. 

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Category: Orthopedics

Title: Concussion Management

Posted: 6/2/2018 by Michael Bond, MD (Emailed: 6/17/2018) (Updated: 6/17/2018)
Click here to contact Michael Bond, MD

Bottom Line:

Less than 1/2 of patients presenting to EDs and being diagnosed with concussion receive mild traumatic brain injury educational materials, and less than 1/2 of patients have seen a clinician for follow up by 3 months after injury.

In order to improve long term outcomes in patients with concusions please remember to provide the patient with approriate discharge instrucitons and strict instructions to follow up on their injury.

Full details of the article in JAMA can be found at https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2681571

 

 


Category: Pediatrics

Title: Occult bacteremia in infants

Keywords: Fever, infants, blood culture (PubMed Search)

Posted: 6/15/2018 by Jenny Guyther, MD
Click here to contact Jenny Guyther, MD

Takeaways

The rate of occult bacteremia in infants 3 months to 24 months with a temperature higher than 40.5C was slightly higher when compared to those with a temperature higher than 39C.

363 infants (3 months to 24 months) with a fever > 40.5C who were well appearing were evaluated in this study.  4 were diagnosed with occult bacteremia (1.1%).  3 of these were caused by S. pneumoniae and 2 were fully immunized.

A larger sample size is needed to see if reconditions to include empiric blood cultures on this subgroup of patients is warrented.

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Category: Toxicology

Title: Midazolam for agitated patients

Keywords: acute agitation, midazolam, antipsychotics, (PubMed Search)

Posted: 6/14/2018 by Hong Kim, MD, MPH (Updated: 7/22/2018)
Click here to contact Hong Kim, MD, MPH

Acutely agitated patients in the emegency room receive single or combination of benzodiazepine (lorazepam vs. midazolam) and antipsychotic (e.g. haloperidol) agents. Recently, use of ketamine has also been advocated to sedate agitated patients.

 

A recently published article compared IM administration several medications to treat acutely agitated patients in the ED. According to established protocol, each medication was administered in predetermined 3 week blocks:

  1. Haloperidol (5 mg)
  2. Ziprasidone (20 mg)
  3. Olanzapine (10 mg)
  4. Midazolam (5 mg)
  5. Haloperidol (10 mg)

Results

N=737 with median age of 40 years, 72% men.

Midazolam resulted in greater proportion of patients with "adequate" sedation (altered mentatl status scale <1) compared to antipsychotics at 15 min post administration. Among antipsychotics, olanzapine resulted in greater proportion of patient with sedation. 

  • Midazolam (71%)
  • Haloperidol - 5 mg (40%)
  • Haloperidol - 10 mg (42%)
  • Olanzapine (61%)
  • ziprasidone (52%)

Adverse effect were limited

  • extrapyramidal AE: 0.3%
  • hypotension 0.5%
  • hypoxemia 1%
  • intubation 0.5%

Conclusion:

Midazolam 5 mg IM achieve more effective sedation at 15 min in agitated ED patients than antipsychotics.

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Category: Neurology

Title: Neuroimaging in Syncope - Is It Necessary?

Keywords: Syncope, neurological, neuroimaging, CT, MRI (PubMed Search)

Posted: 6/13/2018 by WanTsu Wendy Chang, MD (Updated: 7/22/2018)
Click here to contact WanTsu Wendy Chang, MD

  • The use of neuroimaging in syncope-related ED visits increased from 21% in 2001 to 45% in 2010.
  • A recent single-center retrospective study of 1114 patients who presented to the ED with syncope found that 62.3% patients underwent CT, while 10.2% underwent MRI.
  • A subset of patients (10.4%) sustained mild head trauma (GCS 14-15) due to syncope and all received neuroimaging.
  • Neuroimaging studies were not found to be beneficial in patients without features of:
    • Confusion
    • Amnesia
    • Focal neurological deficit
    • Dizziness
    • Severe headache
    • Nausea and vomiting
    • Signs of serious head injury
    • Intracranial malignancies
    • Use of anticoagulant drugs

Bottom Line: Consider obtaining neuroimaging in patients presenting with syncope only if clinical features suggest probable neurological syncope.

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