Ondansetron (Zofran) is a great anti-emetic that, since it has gone generic, is also inexpensive. High dose ondansetron has been reported to cause QT prolongation and that practice is largerly discontinued now in the oncology world. Another uncommon adverse drug reaction may be dystonia. Though we think of ondansetron as a 5-HT3 blocker and should not cause the dystonic reaction like we see in metoclopramide, there are case reports of this reaction occurring.
Tranexamic Acid (TXA) topically applied was compared to anterior nasal packing in 216 patients with acute anterior epistaxis. Cotton pledgets (15 cm) soaked in injectable TXA (500 mg/5 ml) were inserted into the bleeding nostril and removed after bleeding had arrested. This was compared to standard anterior packing.
RESULTS
| TXA Anterior packing |
| % pts bleeding stopped in 10 min: 71% 31.2% |
| Discharge after 2 hours 95.3% 6.4% |
| Rebleeding in 24 h hours 4.7% 11% |
| Satisfaction scores 8.5 4.4 |
Bottom line: topical tranexamic acid looks promising for control of uncomplicated anterior epistaxis.
General Information:
Area of the world affected:
Relevance to the US physician:
Bottom Line:
VRU traffic injuries are the greatest challenge of today's worldwide road safety.
University of Maryland Section of Global Emergency Health
Author: Terrence Mulligan DO, MPH
Mechanical Ventilation During ECMO
34 year-old left-hand dominant male sustained injury to left hand after his pressurized greasing-gun discharged into the palm of his hand. He has a small lac to the hand but is in extreme pain. On exam his hand is very puffy and he is neurovascularly intact (XR below) What is the next step in management?
Myocardial Infarction in Women After Childbirth
World Health Organization reports that obesity is the 5th leading cause of global death with the highest impact on women <65 years of age
The association of obesity and cardiovascular risk in young women is currently being researched
A recent nationwide cohort looking at obesity and future cardiovascular risk looked at Danish women giving birth (2004-2009) and followed them a median time of 4.5 years
This study grouped women via pre-pregnancy body mass index (BMI)
1. Underweight (BMI <18.5)
2. Normal weight (BMI <25)
3. Overweight (BMI <30)
4. Obese (BMI >30)
Data revealed that healthy women of fertile age, pre-pregnancy obesity alone was associated with increased risk of myocardial infarction in the years after childbirth
In most situations (dependant on state laws and institutional policies), methadone-maintained patients enrolled in a drug abuse program are best managed by continuing methadone at the usual maintenance levels with once-a-day oral administration.
Pearl: In the event the methadone clinic is closed and/or the dose cannot be verified, 30-40 mg (10-20 mg IM) is generally enough to prevent withdrawal in most patients.
This is only a short-term measure and some patients may require additional methadone. Full doses of methadone should be reinstituted as soon as possible.
Case Presentation: A 63 year old woman from Texas with no recent international travel presents to the ED with persistent fatigue which onset a month ago and is associated with anorexia and occasional fevers and chills. She has been to her family doctor who tested her for a number of viral illnesses and was told she had West Nile virus.
Clinical Question:
What other febrile illness could this be?
Answer:
This patient had dengue. Dengue is now endemic in the US, and locally-acquired cases have been reported in Florida, Texas and Hawaii. The fatigue and anorexia are typical and can last for weeks after other symptoms have resolved.
West Nile virus testing may be falsely positive when another flavivirus is present such dengue, yellow fever or Japanese encephalitis.
Bottom Line:
Other possible illnesses like dengue should be considered in patients who have tested positive for West Nile virus.
University of Maryland Section of Global Emergency Health
Author: Jenny Reifel Saltzberg, MD, MPH
NSSTIs occur secondary to toxin-secreting bacteria; NSSTIs are surgical emergencies with a high-morbidity / mortality
Risk factors: immunocompromised host (DM, AIDS, etc.), intravenous drug use, malnourishment, peripheral vascular disease
Type I (polymicrobial; most common), Type II (monomicrobial; typically clostridia, streptococci, staph, or bacteroides), Type III (Vibrio vulnificus; seawater exposure)
Signs / Symptoms: pain out of proportion to exam (occasionally no pain at all), skin findings (blistering / bullae, gray-skin discoloration, or “Dishwater-like” discharge), or systemic toxicity (altered mental status, elevated lactate, etc.)
Diagnostic radiology
Treatment is emergent surgical debridement with simultaneous hemodynamic resuscitation PLUS broad-spectrum antibiotics; consider clindamycin becuase it has anti-toxin activity
Adjunctive therapies include Intravenous intraglobulin (neutralizes toxins secreted by bacteria) and hyperbaric oxygen
32 year-old with diabetes presents with fever, erythema, and warmth of his lower extremity; his leg is not particularly painful. He is diagnosed with cellulitis, started on antibiotics, and admitted to the hospital. While boarding in the Emergency Department he becomes rigorous and hypotensive. An ultrasound of his cellulitis is performed and is shown below. What’s the diagnosis?
A 48 year old woman has acute chest pain and palpitations over the past several hours. She has felt similar palpitations in the past but never sought medical attention. She arrives to your ED alert and anxious. HR = 270, BP=130/100. ECG is below. What’s the diagnosis and treatment?
Pelllegrini-Stieda lesion
Ossified post-traumatic lesions at the MCL adjacent to the femoral attachment site of the medial femoral condyle.
Mechanism is likely from an avulsion injury that subsequently calcifies after the initial trauma.
Often an incidental finding on plain films.
If symptomatic, refer to ortho as an outpatient
If not symptomatic, no treatment is indicated
http://images.radiopaedia.org/images/30076/b62e61e83241e30f2da693901edcdc_gallery.jpg
http://www.imageinterpretation.co.uk/images/knee/PELLEGRINI%20STIEDA2.jpg
Everyone has admitted an altered mental status, patient or bradycardic patient and all of your test results are coming back normal except for a mild increase in creatinine. Take a look at the medication list. Creatinine is a poor indicator of renal function and GFR may be severely impaired even with a mild elevation of creatinine. If you have a predominantly renally excreted drug, you can see toxic effects of a drug even if administered at therapeutic levels.
Common bradycardia inducing medication that is renally cleared: atenolol (very high renal excretion) and digoxin (70%).
Altered Mental Status and on Keppra? Keppra is 100% renally cleared!
Ask your pharmacist for help with the medication list with renal or hepatic insufficiency.
98% of venomous snake bites in the US are due to pit vipers. Occasionally a snake bite is from an exotic venomous snake being kept as a pet. In 2005, 142 exotic poisonous snakes were reported to poison control. It can be very challenging to find antivenom for these exotic animals.
Antivenom is usually specific to a family or subfamily, so the snake must be identified. Most exotic snake owners will know the common name and possibly the scientific name of the animal.
The WHO database of venomous snakes can help with identification of the species and will list antivenom available globally.
Poison centers are essential to help locate the antivenom and assist with treatment.
Relevance to the EM Physician:
When a patient presents with an exotic snake envenomation, the WHO website below can be helpful to identify the species and possible antivenom.
http://apps.who.int/bloodproducts/snakeantivenoms/database/
University of Maryland Section of Global Emergency Health
Author: Jenny Reifel Saltzberg
Arterial Catheter-Related Blood Stream Infections
Whether arterial lines are a potential source of catheter-related blood stream infections (CRBSIs) is highly-debated; however, based on a recent systematic review they are an under recognized and significant source of CRBSIs.
Bottom Line(s)
50 year-old male intubated for respiratory distress. Ultrasound is used post-intubation to confirm tube placement and the following images are obtained. What's the diagnosis?
Pacing Atrioventricular Block
- Atrioventricular (AV) block is classically treated with restoration of heart rate via right ventricular pacing, however high rates of right ventricular pacing is associated w/ left ventricular systolic dysfunction
- A recent multi-center randomized control trial (RCT) assessed the efficacy of right vs biventricular pacing in heart failure w/ AV block [BLOCK HF Trial]
- Primary outcomes of: morbidity, mortality, and adverse left ventricular remodeling were shown to be significantly lower in biventricular vs right ventricular pacing
- In patients with a high rate of pacing and/or an abnormally low left ventricular ejection fraction biventricular pacing may be more advantageous than conventional right ventricular pacing
Post Operative Fever is extremely common, and with the increase in same day surgery this is a common complaint presenting to the ED. The mnemonic "5Ws" are often taught to remember the causes. They are:
Though many surgical textbooks report that atelectasis is the most common cause of early post-operative fever, some even claiming that it is responsible for over 90% of febrile episodes in the first 48 hours after surgery; a recent review in CHEST (reference below) showed that there is no evidence to support this. We often see atelectasis in medical patients too, and few if any of them have fever. The CHEST review found that there was no clear evidence that atelectasis causes fever at all.
Pearl: Temperature >38.9C should raise concern for a true infection, where lower temperatures can be due to pulmonary embolism, DVT, drug fever, etc….
