Transplant patients are the norm now in the ED. Their drug lists are immense and are usually on some form of immunosuppression to prevent rejection of the transplanted organ. Two common medications are cyclosporine and tacrolimus. They share many adverse effects like hepatotoxicity, nephrotoxicity and hypertension. Here is the mechanism of action and some unique adverse effects to these powerful immunosuppressants (there are many more so be wary):
1) Cyclosporine - suppresses T-cell activation and growth. Unique toxicity - painful neuropathy of the fingertips and toes, cortical blindness
2) Tacrolimus - simiar to cyclosporine but actually hampers T-cell communication/signal transduction. Unique toxicity - can also cause cortical blindness but is also known to cause diabetes/hyperglycemiad
Two recently presented abstracts at the 2012 Society of Critical Care Medicine conference suggest that the combination of vancomycin and piperacillin-tazobactam may lead to acute kidney injury (AKI) in the critically ill. There may also be evidence to suggest that piperacillin-tazobactam alone increases the risk of AKI.
Both abstracts retrospectively compared patients who received either vancomycin alone or the combination of vancomycin and piperacillin-tazobactam. In both studies, the rates of AKI were significantly lower in patients treated with vancomycin alone as compared to patients receiving both vancomycin and piperacillin-tazobactam.
Bottom line: Although the current evidence does not support a change in our clinical practice, more prospective studies exploring this topic are necessary.
79 year old male with headaches, ataxia, falls, and difficulty urinating. What's the diagnosis?
For patients presenting to the ED with chest pain, we've been taught that “classic” or “typical” presentations for ACS (chest pressure with radiation to the left neck/jaw/shoulder/arm, dyspnea, diaphoresis, nausea, vomiting, lightheadedness) are most worrisome. Yet, many of the patients that present with typical symptoms end up having negative workups for ACS. What are the symptoms that truly predict ACS? Three major studies have demonstrated that the best predictors of ACS in patients presenting to the ED with chest pain are (not necessarily ranked in order):
1. chest pain that radiates to the arms, especially if the pain radiates bilaterally or to the right arm
2. chest pain associated with diaphoresis
3. chest pain associated with vomiting
4. chest pain associated with exertion
The description of the chest pain (e.g. "pressure" or "squeezing," etc.), the dyspnea, nausea, lightheadedness, and pain at rest were, surprisingly, not helpful at predicting ACS.
The simple takehome point is the following: always ask your patient with chest pain if the pain radiates, if there was associated diaphoresis, if there was associated vomiting, and if the pain is associated with exertion. If the answers to any of these 4 questions is "yes," think twice before labeling the patient with a non-ACS diagnosis.
Contrast Allergy:
Many patients will report that they have a allergy to iodinated contrast by saying that they are allergic to iodine
Iodine, itself, is not an allergen and is a required element for thyroid homrone production. Plus could you imagine the hordes of people that would be having allergic reactions everyday when they add salt to their french fries. Our EDs would be completely swamped.
A recent meta-analysis by Drs. Schabelman and Witting also showed the following:
As we enter Crab eating season in Maryland, lets stop giving shellfish a bad name. A patent with any allergy is at increased risk, but shellfish is no higher a risk than those allergic to Strawberries.
Definition: Fracture of the humerus just proximal to the epicondyles.
Use the Measured Sodium Concentration!
19 year-old male presents with L ankle pain and obvious deformity after jumping out of a window and landing on his inverted foot. What's the diagnosis?
New studies are utilizing mild therapeutic hypothermia as a treatment option in cardiogenic shock. These studies have reported improved circulatory support, an increase in systemic vascular resistance, and reduction in vasopressor use which ultimately may result in lower cardiac oxygen consumption. The preliminary results suggest that mild therapeutic hypothermia could be a therapeutic option in hemodynamically unstable patients independent of current recommendations which support its use in cardiac arrest survivors.
• Wedge compression fractures
http://jbjs.org/data/Journals/JBJS/855/JBJA0851224560G02.jpeg
It may not be necessary to give oral vitamin K to patients that are not bleeding that have INRs between 4.5 and 10.
Patients who were supratherapeutic on warfarin were randomized to vitamin K 1.25 mg (n=355) versus placebo (n=369).
In the 90 days after enrollment, 15.8% of patients allocated to vitamin K and 16.3% allocated to placebo had a bleeding event. Major bleeding events occurred in 9 patients in the vitamin K group and 4 in the placebo.
Thromboembolic events occurred in 1.1% of patients in the vitamin K group, compared to 0.8% of patients in the placebo group. An equal number of patients died in each group (n=7).
Consider rhabdomyolyisis secondary to heat exposure as summertime approaches; have a low threshold to screen patients if they are at risk (e.g., people exercising in high-ambient temperatures).
Symptoms include muscle tenderness, cramping, and swelling with associated weakness. Patients with altered mental status (e.g., heat stroke) should be examined for limb induration, skin discoloration (i.e., ischemia), or compartment syndrome.
Complications:
Treatment
Naltrexone and methylnaltrexone are both mu-receptor antagonists that look similar and have similar names. But, they have very different uses.
Severe UGIB
Ultrasound is useful during intubation; here is a video explaining how: http://ultrarounds.com/ultrarounds.com/Visual_Pearl_May_28,_2012.html
Today's Bonus Pearl:
EMRA has developed a great antibiotic guide for the iphone (http://itunes.apple.com/us/app/2011-emra-antibiotic-guide/id393020737?mt=8) or android (https://play.google.com/store/apps/developer?id=Emergency+Medicine+Residents'+Association). This app is a bit pricey ($15.99), but is easy to use and well organized. Enjoy!
[pearl provided by Dr. Semhar Tewelde]
Myocarditis is an under-diagnosed cardiac disease resulting from a broad range of infectious, immune, and toxic etiologies
Hamate Fractures
Occur in two locations: the body of the hamate and the hook (hamular process) of the hamate
Fractures are present in 2 to 4% of carpal bone fractures
Body fractures are less common and are associated with dislocation of the fourth and fifth metacarpals
Axial force transmitted down the metacarpal shaft (a fall or fist strike)
Hook fractures occur from a direct force from an object strikes the palm such as that from a bat, golf club or racket
Have increased suspicion in these athletes who present w/ ulnar sided wrist pain
Diagnosis is frequently missed; chronic fractures are associated w/ flexor tendon rupture and ulnar neuropathy
PE: Tenderness localized over the hamate (in the hypothenar eminence) and over the dorsal ulnar aspect of the wrist. Swelling may be present. Look for resisted flexion of the 5th digit when the wrist is held in ulnar deviation. May note sensory changes in ulnar nerve distribution
Imaging: PA and lateral views of the wrist will show a body fracture but will frequently MISS a fracture of the hook of the hamate. In those with a clinical suspicion for this entity, order a “carpal tunnel view.” In the proper clinical setting, CT imaging is excellent for those with high suspicion and normal plain films.
Proper Feeding of the Newborn
The emergency physician must be comfortable with providing anticipatory guidance to parents of newborn, especially with regards to proper feeds of the neonate.
Newborns will lose some weight in the first 5-7 days of life. A 5% weight loss is considered normal for a formula fed newborn. A 7%-10% loss is considered normal for the breastfed baby. Most babies regain their birth weight by days10-14 of life. During the first 3 months, infants gain about an ounce a day (30 g) or 2 pounds a month (900 g). By age 3-4 months, healthy term infants have doubled their birth weight.
Breast-fed Neonates:
- Should be fed every 2-3 hours while awake
- 5-20 minutes of sucking per breast
- May gain weight slower than formula-fed counterparts
Formula-fed Neonates:
- 0.5-1 ounces per feeding every 3-4 hours for the 1st week
- Then 1-3 ounces per feeding every 3-4 hours
- Typical formula contains 20 cal/ounce
In general, overfeeding during the neonatal period has been associated with adult obesity. The American Academy of Pediatrics recommends exclusive breastfeeding for at least the 1st 6 months of life. Earlier switches to formula has been associated with atopy, diabetes and obesity
References:
- Fleischer DM. “Introducing formula and solid foods to infants at risk for allergenic disease.” UptoDate;2012.
- Hammer LD, et al. “Development of feeding practices during the first 5 years of life.” Nutrition;1999;189-194.
- Philips SM and Jensen C. “Dietary history and recommended dietary intake in children.” UptoDate;2011.
- Prior LJ and Armitage JA. “Neonatal overfeeding leads to developmental programming of adult obesity.” J Physiol;2009:2419.
