UMEM Educational Pearls

Category: Pediatrics

Title: Can you glue a pediatric nail bed laceration?

Keywords: Nail bed injuries, wound closure (PubMed Search)

Posted: 1/20/2017 by Jenny Guyther, MD (Updated: 1/23/2017)
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Takeaways

More studies are needed, but the existing data shows that medical adhesives may be quicker without impacting cosmetic and functional outcome.

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Category: Toxicology

Title: Urine drug testing

Keywords: Urine Drug Sreen (PubMed Search)

Posted: 1/19/2017 by Kathy Prybys, DO (Emailed: 1/20/2017) (Updated: 1/20/2017)
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Urine drug screens are most commonly performed by immunoassay technology utilizing monoclonal antibodies that recognizes a structural feature of a drug or its metabolites.  They are simple to perform. provide rapid screening, and qualitative results on up to 10 distinct drug classes with good sensitivity but imperfect specificity. This can lead to false positive results and the need for confirmatory testing. UDS  does not detect synthetic opiates or cannabinoids, bath salts (synthetic cathinones), and  gamma-hydroybutyrate. Most common drug classes detected are the following:

  • Opiates
  • Methadone
  • Benzodiazepines (not all)
  • Amphetamines 
  • Cocaine
  • THC metabolites
  • Barbituates
  • LSD
  • PCP
  • MDMA (Ecstasy)

 

 

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Category: International EM

Title: Opioids- A Major Killer

Keywords: Opioids, overdose, injury, death (PubMed Search)

Posted: 1/18/2017 by Jon Mark Hirshon, MD, MPH
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·       Opioid deaths, such as from heroin and prescription opioids, are a major problem globally

·       In the U.S., since 1999 overdose deaths from prescription opioids have quadrupled.

o   Almost half of opioid deaths involve a prescription opioid

·       The most common drugs related to prescription opioid deaths are:

o   Methadone

o   Oxycodone

o   Hydrocodone

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Category: Critical Care

Title: Ultrasound Guided Radial Arterial Lines

Keywords: Arterial Line, Ultrasound (PubMed Search)

Posted: 1/17/2017 by Rory Spiegel, MD (Updated: 1/23/2017)
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It is not uncommon for critically ill patients to require invasive monitoring of their blood pressure. In these patients, radial arterial lines are often inserted. Traditionally these lines are placed using palpation of the radial pulse. This technique can lead to unacceptably high failure rate in the hypotensive patient commonly encountered in the Emergency Department.

A recent meta-analysis by Gu et al demonstrated the use of dynamic US to assist in the placement of radial arterial lines decreased the rate of first attempt failure, time to line insertion and the number of adverse events associated with insertion.

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Category: Orthopedics

Title: Exercise Induced Bronchospasm (EIB) in Athletes

Keywords: Airway, wheezing, exercise (PubMed Search)

Posted: 1/14/2017 by Brian Corwell, MD (Updated: 1/23/2017)
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Respiratory symptoms are often the basis for the diagnosis and treatment of EIB.

Self-reported Sx’s (cough, chest tightness, SOB, wheezing) have both poor sensitivity and poor specificity for diagnosis.

          Of these, wheezing is most predictive

Symptoms do not correlate with changes in airway caliber in athletes with EIB.

78% of family physicians and almost 50% of pulmonologists start empiric treatment before exercise based on reported symptoms.

Approximately 50% of athletes with symptoms of EIB in this study did not have EIB when PFTs were performed.

Physicians should not rely solely on symptoms for EIB diagnosis.

Also, improvement in self-reported symptoms after administration of beta2 agonists should not be used to make a formal diagnosis.

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Category: Toxicology

Title: Risk factors of severe outcome in acute salicylate poisoning

Keywords: salicylate poisoning (PubMed Search)

Posted: 1/13/2017 by Hong Kim, MD, MPH (Updated: 1/23/2017)
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A small retrospective study of an acute poisoning cohort attempted to identify risk factors for severe outcome in salicylate poisoning.

Severe outcomes were defined as

  1. Acidemia pH < 7.3 or bicarbonate < 16 mEq/L
  2. Hemodialysis
  3. Death

A multivariate analysis of 48 patients showed that older age and increased respiratory rate were independent predictors of severe outcomes when adjusted for salicylate level.

Initial salicylate acid level was not predictive of severe outcome.  

Elevated lactic acid level was also a good predictor of severe outcome in univariate analysis but not in multivariate analysis.

Limitations

  1. Small sample size with single center study
  2. Retrospective study design
  3. Validation study of these predictors is needed.

 

Bottom line

  1. Older age and increases respiratory rate is associated with severe outcome (acidemia, hemodialysis or/and death) in this study.
  2. Data must be interpreted with caution due to small sample and retrospective study design.

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Category: Neurology

Title: Driving after concussion: Is it safe to drive after symptoms resolve?

Keywords: concussion, driving performance, cognitive impairment (PubMed Search)

Posted: 1/11/2017 by WanTsu Wendy Chang, MD
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Driving after concussion: Is it safe to drive after symptoms resolve?
  • Limited data is available to guide when individuals should return to driving after a concussion.
  • Cognitive impairments in reaction time, executive function, and attention can persist even after symptoms of a concussion resolve.
  • Schmidt et al. compared driving performance between individuals within 48 hours following symptom resolution after a concussion with matched controls using simulated driving.
  • They found that concussed individuals had poorer driving performance despite being asymptomatic.
  • This study is limited by a small sample size (n=28), however, it raises interesting questions regarding whether driving should be restricted following concussions and how should readiness to return to driving be determined.

 

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Question

A 60 year-old man with history of atrial fibrillation, CAD presents with left lower leg/foot pain for a few days. His foot is seen below. What's the diagnosis?

 

 

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Category: Pharmacology & Therapeutics

Title: Ketorolac's analgesic ceiling

Keywords: ketorolac, NSAID, analgesia (PubMed Search)

Posted: 1/7/2017 by Michelle Hines, PharmD (Updated: 1/23/2017)
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Takeaways

In a study comparing ketorolac IV doses of 10 mg, 15 mg, and 30 mg, no difference in pain score reduction or need for rescue analgesia was observed.

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Category: Toxicology

Title: Unexplained Lactic Acidosis, a clue to poisoning

Keywords: Lactic acidosis (PubMed Search)

Posted: 1/5/2017 by Kathy Prybys, DO (Emailed: 1/6/2017) (Updated: 1/6/2017)
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Lactic acidosis is the most common cause of anion gap metabolic acidosis in all hospitalized patients. An elevated lactate level is an important marker of inadequate tissue perfusion causing subsequent shift to anaerobic metabolism and occuring in a variety of disease states such as sepsis. In patients with unexplained lactic acidosis without systemic hyoperfusion or seizure suspect  the following toxins:

  • Acetaminophen: Early on in massive ingestion usually associated with coma.
  • Cyanide
  • Metformin
  • HIV Drugs: Nucleotide reverse transcriptase inhibitors = Didanosine, stavudine, zidovudine due to mitochondrial toxicity.
  • Ethylene Glycol: Spuriously elevated lactate may occur with ethylene glycol toxicity due to the structural similarity between glycolic acid and lactate.Check for osmolar gap.
  • Kombucha ``mushroom'' tea 
 

 

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Category: International EM

Title: Vitamin B12 Deficiency: Part 2

Keywords: B12 deficiency, ataxia, dementia, pernicious anemia (PubMed Search)

Posted: 1/4/2017 by Jon Mark Hirshon, MD, MPH
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Vitamin B12 deficiency can cause significant disease, including severe neurologic problems. However, patient presentations can vary greatly.

Signs and symptoms can include:

  • Constitutional symptoms: fatigue, lack of energy, lightheadedness, loss of appetite
  • Gastrointestinal problems: diarrhea or constipation
  • Cardiovascular: shortness of breath, dyspnea on exertion, tachycardia, CHF
  • Oral lesions: swollen, red tongue (glossitis) or bleeding gums
  • Problems concentrating

Prolonged B12 deficiency can lead to significant neurologic complications, frequently related to the spinal cord, and can include:

  • Mild impairment to dementia
  • Depression, psychosis
  • Loss of balance, limb weakness, ataxia
  • Peripheral neuropathy (numbness and tingling of hands and feet)

PaCO2 and the Post-Arrest Patient

  • Alterations in PaCO2 are common during the post-arrest period and have been associated with worse patient centered outcomes.
  • Hypercarbia can dilate cerebral vessels, increase cerebral blood flow, and may increase intracranial pressure.
  • Conversely, hypocarbia can constrict cerebral vessels and may reduce cerebral blood flow.
  • Though the current evidence is primarily limited to observational trials, a recent meta-analysis found that "normocarbia" was associated with improved hospital survival and neurologic outcome. 
  • Take Home: Adjust mechanical ventilation to target normocarbia (PaCO2 or ETCO2) in the post-arrest patient.

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Question

A 36-year-old male, who recently immigrated from Africa, presented to the ED with fever, rash, cough and shortness of breath. He was noted to be febrile to 39.0 C. The rash is disseminated but present mainly in his trunk as shown in the picture. 

 

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Takeaways

Take Home Point:

  • According to a recent article in the NEJM there does not seem to be any difference in the rate of symptomatic venous thromboembolism (VTE) in patients given low molecular weight heparin that underwent arthorscopy or had lower leg casting at 3 months.  
  • Overall, the rates of VTE were really low ( casting: 1.4% vs. 1.8%; arthroscopy: 0.7% vs. 0.4%), so there is probably not need for prophalaxis in these patients. 

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In pediatrics, providers typically prescribe 10 mg/kg (max 500 mg) and 5 mg/kg daily x 4 (max 250 mg) for treatment of pneumonia, but this dosing regimen is NOT recommended for all azithromycin usage. There are other dosing regimens that are important to keep in mind during the respiratory season:

1) Pharyngitis/ tonsillitis (ages 2-15 yr): 12 mg/kg daily x 5 days (max 500 mg/ 24 hr)

2) Pertussis

3) Acute sinusitis >/= 6 months: 10 mg/kg daily x 3 days

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Category: Toxicology

Title: Utility of lactic acid level for diagnosis of cyanide poisoning in smoke inhalation victims

Keywords: cyanide toxicity, lactic acid (PubMed Search)

Posted: 12/29/2016 by Hong Kim, MD, MPH (Emailed: 12/30/2016) (Updated: 12/30/2016)
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Takeaways

Smoke inhalation victims (house fires) are at risk of carbon monoxide (CO) and cyanide poisoning (CN). CO exposure/poisoning can be readily evaluated by CO - Oximetry but CN level can be obtained in majority of the hospital.

Lactic acid level is often sent to evaluate for CN poisoning.

 

Bottom line:

  1. Lactatic acid levels should be sent in all smoke inhalation victims.
  2. Elevate lactate > 10 mmol/L is highly suggestive of CN poisoning
    .

 

 

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Category: Critical Care

Title: Bolus Dose Nitrates in Acute Pulmonary Edema

Keywords: Acute pulmonary edema, Bolus nitrates (PubMed Search)

Posted: 12/27/2016 by Rory Spiegel, MD (Updated: 1/23/2017)
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It is well known that the early aggressive utilization of IV nitrates and non-invasive positive pressure ventilation (NIV) in patients presenting with acute pulmonary edema will decrease the number of patients requiring endotracheal intubation and mechanical ventilation. 

Often our tepid dosing of nitroglycerine is to blame for treatment failure. Multiple studies have demonstrated the advantages of bolus dose nitroglycerine in the early management of patients with acute pulmonary edema. In these cohorts, patients bolused with impressively high doses of IV nitrates every 5 minutes, are intuabted less frequently than patients who received a standard infusion (1,2). No concerning drops in blood pressure in the patients who received bolus doses of nitrates were observed. Using the standard 200 micrograms/ml nitroglycerine concentration, blood pressure can be rapidly titrated to effect.

 

 

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Question

68 year-old male presents with 3-4 days of hedache, anorexia for 2 weeks and "balance trouble." His blood pressure was 226/140 and he states he has not been on his medications for 6 months.
Physical examination revealed a shuffled gait with his walker and the rest of his physical exam and neurologic exam was unremarkable. 
 
His CT is seen below. What's the diagnosis?
 
 
 
 

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Category: Orthopedics

Title: Concussions injure more than your head

Keywords: Concussions, musculoskeletal injury (PubMed Search)

Posted: 12/24/2016 by Brian Corwell, MD
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Concussions are associated with an elevated risk of musculoskeletal injury

 

Significant associations were found between concussion and

Lateral ankle sprain (P = 0.012)

Knee injury (P = 0.002)

Lower extremity muscle injury (P = 0.031)

Keep in mind that 50 – 80% of concussions may go undiagnosed or unreported.

A discussion about risks of early return after concussion should include mention of risks beyond repeat head injury/2nd impact syndrome

Study limits: Retrospective design limits ability to establish causation/reporting bias

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Vitamin B12 deficiency, including pernicious anemia, is typically seen in malnourished individuals. Globally, it is widespread in those who live in poverty.

In the U.S., we often consider it in individuals who are chronic alcoholics. However, it can be seen in others, including:

  • Bariatric patients after certain weight-loss surgeries
  • Conditions causing problems with food digestion, including Crohn’s disease, celiac disease, or fish tapeworm (Diphyllobothrium latum) infection
  • Individuals on certain medications for a prolonged time, including proton pump inhibitors, histamine 2 receptor blockers and metformin
  • Inadequate dietary intake or genetic intrinsic factor deficiency