UMEM Educational Pearls

Category: Misc

Title: Wound Repair

Keywords: Wound, Repair (PubMed Search)

Posted: 7/30/2011 by Michael Bond, MD
Click here to contact Michael Bond, MD

Wound Repair

A pearl last year addressed the irrigation of wound and the fact that the type of fluid (sterile versus tap water) does not affect infection rates but rather the volume of irrigation is most important.

Sterile versus unsterile gloves have also been studied, and it turns out that clean unsterile gloves have the same rate of infection as sterile gloves but come with a substantial cost savings.

When caring for a contaminated wound it is most important to remove any gross contamination, and then irrigate the wound as much as possible.  A 20 mL syringe with an 18G angio-catheter provides the proper pressure to remove debris without causing tissue damage. The wound can then be closed wearing the gloves that are most comfortable or accessible to you.

Finally, from a medicolegal standpoint it is always best to inform the patient that you have tried to remove all of the contamination but there is still a chance that the wound can get infected. 



Acute Poststreptococcal Glomerulonephritis (APSGN) is a sequela of group A beta-hemolytic streptococci (GAS) infection of the skin or pharynx with nephrogenic strains of GAS.  Damage to the kidneys is due to deposition of antigen-antibody complexes in the glomeruli

Presentation:

- Onset of APSGN averages 10 days after pharyngitis and 3 weeks following cellulitis.
- Nephritic syndome - hematuria (classically "coa-colored"), mild proteinuria, edema (periorbital), hypertension
- Additional symptoms: orthopnea, dyspnea (volume overload), lethargy, vomiting, fever, headache

Testing:

- Urinalysis (hematuria, proteinuria), creatinine (with subsequent hyperkalemia, acidosis)
- Bacterial cultures of skin or pharynx not useful as rarely positive at time of presentation
- Antistreptolysin O (ASO) titer elevated if preceding pharyngitis but rarely skin infections
- Antideoxyribonuclease B (anti-DNAse B) titers typically elevated in both
- Suppressed C3 level

Treatment:

- Predominately symptomatic: salt an water restriction
- Treatment of hyperkalemia, hypertension (loop diuretics)
- Antibiotics vs GAS (although does not affect clinical course of APSGN, eradicates GAS in individual and reduces transmission of nephrogenic GAS to community
- Profound renal failure may require hemodialysis or peritoneal dialysis

Prognosis (favorable):

- Hypertension and gross hematuria resolve over weeks (microscopic may last years)
- Proteinuria resolves over months
- Creatinine returns to baseline over 3-4 weeks

 

Reference:

Kit, Brian. Assess the volume status and electrolytes in children with poststreptococcal glomerulonephritis. Avoiding Common Pediatric Errors. 2008. p356-57.



Category: Toxicology

Title: Fluoroquinolone-Induced Tendon Rupture

Keywords: fluroquinolone, tendon rupture (PubMed Search)

Posted: 7/28/2011 by Bryan Hayes, PharmD
Click here to contact Bryan Hayes, PharmD

The incidence of tendon rupture related to fluoroquinolone use is reported to be in the range of 1 in 6000.

The risk of tendon rupture associated with FQ use is increased in those older than 60 years of age, those taking steroids, and in patients who have received heart, renal, or pulmonary transplants.

There is no evidence that tendon rupture is more likely for patients taking levofloxacin compared to other FQs.

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Category: Neurology

Title: Central Pontine Myelinolysis - What it is and How to Prevent it

Keywords: central pontine myelinolysis, hypernatremia (PubMed Search)

Posted: 7/27/2011 by Aisha Liferidge, MD (Updated: 3/29/2024)
Click here to contact Aisha Liferidge, MD

  • Central Pontine Myelinolysis (CPM) is a largely irreversible, dreaded neurologic complication caused by osmotic demyelination, as a result of increasing sodium levels too rapidly.  It is definitively diagnosed via Brain MRI.
  • Symptoms may include dysphagia, dysarthria, paraparesis, quadriparesis, lethargy, seizure, or even coma, and usually begin within 2 to 6 days following sodium elevation (i.e. may not be apparent in the emergency department).
  • If the hyponatremic patient is symptom-free, treat conservatively by restricting oral fluid intake to less than 1500 mL per day.  Isotonic fluids (i.e. 0.9% normal saline) may be used, particularly if the patient is dehydrated.
  • If the hyponatremic patient is symptomatic, hypertonic saline (i.e. 3%, start with 100 mL bolus) may be used.
  • Increase sodium level by no more than 1.5 to 2 meq/L per hour for the first 3 to 4 hours until symptoms resolve.  Increase by no more than 10 meq/L in the first 24 hours.
  • Take Home Point Prevent devastation of CPM by treating asymptomatic hyponatremia conservatively and by closely monitoring rate of sodium increase.


Blood Pressure in the Critically Ill Obese Patient

  • Recall that incorrectly sized cuffs can significantly overestimate blood pressure, especially in obese patients.
  • In fact, some studies show that false BP readings can occur in up to 75% of obese patients.
  • By relying solely on noninvasive BP measurements, many of your critically ill obese patients may actually be hypotensive and under perfused.
  • When you've got a sick obese patient, strongly consider early placement of an arterial line to assess and monitor blood pressure.

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Category: Visual Diagnosis

Title: What's the Daignosis?

Posted: 7/25/2011 by Haney Mallemat, MD (Updated: 8/28/2014)
Click here to contact Haney Mallemat, MD

Question

34 y.o. male with history of IVDA (intravenous drug abuse) complains of fever, chills and cough. Diagnosis?


Show Answer

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Category: Cardiology

Title: RV infarction

Keywords: myocardial infarction, right ventricle, right ventricular (PubMed Search)

Posted: 7/24/2011 by Amal Mattu, MD
Click here to contact Amal Mattu, MD

Clues to RV infarction:

1. This almost always occurs in the presence of a concurrent inferior MI.
2. Clinical findings may include the triad of hypotension, JVD, and clear lungs.
3. ECG clues: in the presence of inferior lead ischemia or injury pattern, look for:
     a. Combination of ST depression in lead V2 + ST elevation in lead V1; OR
     b. Combination of ST depression in lead V2 + isoelectric ST segments in leads V1 and V3; OR
     c. ST elevation in lead III markedly greater than the ST elevation in lead II; OR
     d. ST elevation in right-sided leads (requires you to obtain right-sided leads)

Why is this diagnosis important?
1. It suggests a larger infarction and worse prognosis, so BE AGGRESSIVE in management.
2. Be very cautious with preload-reducing medications (e.g. nitrates) in the acute management of these patients, as they may induce significant reductions in blood pressure and extension of the infarction. Be aggressive with IVF, while maintaining close attention to the lung sounds.

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Category: Orthopedics

Title: Refractory Osteomyelitis

Keywords: Osteomyelitis, hyperbaric oxygen (PubMed Search)

Posted: 7/23/2011 by Brian Corwell, MD
Click here to contact Brian Corwell, MD

Refractory Osteomyelitis is defined as a chronic osteomyelitis that persists or recurs after appropriate interventions have been performed or where acute osteomyelitis has not responded to surgery and antibiotics.

Case series, animal data and non-randomized prospective trials suggest that the addition of Hyperbaric Oxygen therapy to routine surgical and antibiotic management of previously refractory osteomyelitis is safe and improves the rate of infection resolution.

In patients with osteomyelitis involving spine, skull, sternum,  HBOT  is recommended prior to surgical intervention.  

Typically patients require 20-40 daily dives for sustained therapeutic benefit. 

How does HBOT work in osteomyelitis?

1.       Restoration of normal to elevated O2 level in infected bone.

2.       Leukocyte mediated killing of aerobic bacteria is restored when low O2 tension intrinsic to osteomyolitic bone is restored to physiologic or supra-physiologic levels.

3.       HBOT is noted to exert direct suppressive effects on anaerobic infections.

4.       HBOT augment the transport of certain abx (aminoglycosides and cephalosporins) across bacterial cell wall.

5.       Enhance osteogenesis

6.       Enhance angiogenesis

 

thank you to Dr. Sethuraman for this pearl

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You're called to bedside to evaluate a "lethargic" infant.  You wisely ask for a POCT glucose which returns at 35.  How much dextrose do you give (since you know it's not just "an amp" of D50?

Here's a simple mnemonic:

Rule of 50-100 = multiply type of dextrose solution by ____ factor (ml/kg) to total 50-100

D10 (neonate) x 5-10 ml/kg = 50-100

D25 (infant) x 2-4 ml/kg = 50-100

D50 (child/adolescent) x 1-2 ml/kg = 50-100



Category: Toxicology

Title: Bath Salts on the RIse

Keywords: mephedrone (PubMed Search)

Posted: 7/21/2011 by Fermin Barrueto, MD (Updated: 3/29/2024)
Click here to contact Fermin Barrueto, MD

There are increasing reports of bath salts which are crushed and then either injected, insufflated or taken orally. The actual substance has been found to be mephedrone as well as MDPV.(1)  Both are amphetamine derivatives and the psychosis seen can appear like schizophrenia to the point that some of these patients have been admitted to the psychiatric wards. (2)(3)  For those who have seen methamphetamine patients "tweaking" - where they use the drug for several days in a row without sleep - the presentation is quite similiar.

Synthetic drugs continue to present legal and regulatory problems since the compound is a "designer" synthesized drug that may not be on the DEA Schedule list.  The product is labeled "Not for human consumption". Head shops and the internet remain primary sources of the drug. Bath salts present a serious and dangerous public health risk.

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Category: Neurology

Title: What is PRES?

Keywords: PRES, posterior reversible encephalopathy syndrome (PubMed Search)

Posted: 7/20/2011 by Aisha Liferidge, MD
Click here to contact Aisha Liferidge, MD

  • Posterior Reversible Encephalopathy Syndrome (PRES) is a relatively newly-recognized condition characterized by headache, convulsions, confusion, and vision loss (i.e."CCCV," "Cephalgia,Convulsions, Confusion, Vision loss.")
  • Risk factors include:  severe hypertension, eclampsia, renal failure, and use of immunosuppressive medications such as tacrolimus and cyclosporine; low magnesium levels may exacerbate PRES.
  • PRES may be under-recognized because its diagnosis is based on both clinical and radiographic findings.  Brain MRI findings classically show bilateral hyperintense densities in the parieto-occipital regions on T2 weighted images (see attached image).
  • Treatment of PRES consists of managing the underlying cause such as lowering blood pressure and discontinuing offending medications, which typically results in resolution of symptoms.
  • Take Home PointConsider PRES as the etiology of unexplained constellations of symptoms including headache, seizure, confusion, and vision loss in the setting of severe hypertension, particularly amongst patients with renal failure and on immunosuppressants.

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Attachments

1107201545_PRES_MRI.jpg (13 Kb)



Category: Critical Care

Title: Heat Stroke? Time to Chill.

Keywords: heat stroke, critical care, acute kidney injury, seizures, neurological (PubMed Search)

Posted: 7/19/2011 by Haney Mallemat, MD
Click here to contact Haney Mallemat, MD

Heat stroke is hyperthermia (>41.6 Celsius / 106 Fahrenheit) plus neurologic findings (e.g., altered mental status, seizures, coma, etc.); it also causes systemic inflammation response syndrome (i.e., cytokine release), coagulation disorders (e.g., thrombosis in end organs) and tissue abnormalities (e.g., acute kidney injury and rhabdomyolysis)

Two classifications exist:

  • Exertional heatstroke (young people engaged in strenuous physical activities in hot climates)
  • Non-exertional heatstroke occurring in sedentary people (elderly, debilitated, or chronically-ill patients) who are unprotected from the elements (e.g., trapped in apartments during heat waves)

Treatment includes:

  • Insertion of a continuous core thermometer
  • Supporting ABC’s
  • Cooling by at least to 0.2 degrees celsius per minute to 39 degrees (to avoid overshoot)
  • Benzodiazepines for sedation, shivering, and seizures
  • Antipyretics and phenytoin have not been shown beneficial
  • Support and protect end-organs with particular attention to kidneys; increased risk of kidney injury from rhabdomyolysis, ischemia and systemic inflammation.

Despite the most aggressive therapy, up to 30% survivors may have permanent neurologic or multi-organ system dysfunction months to years after recovery

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Category: Cardiology

Title: phenylephrine

Keywords: phenylephrine (PubMed Search)

Posted: 7/17/2011 by Amal Mattu, MD (Updated: 3/29/2024)
Click here to contact Amal Mattu, MD

With recent national shortages of norepinephrine, our typical go-to drug in sepsis, it's become important for us all to familiarize ourselves with alternative pressors in this setting. Phenylephrine is a commonly chosen alternative.

Phenylephrine is a potent alpha-agonist associated with peripheral vasoconstriction. It has no beta effects so it is not associated with tachydysrhythmias. On the other hand, it is associated with reflex bradycardia which can be treated or prevented with atropine (although there are no specific recommendations to routinely administer atropine prophylactically). Phenylephrine may take 10 minutes to demonstrate an effect, and its duration is approximately 15 minutes. It should be used cautiously in patients with underlying cardiac disease because of the vasoconstrictive effect, and it should be avoided in patients with narrow-angle closure glaucoma.

Extravasation can cause tissue necrosis and should be treated with phentolamine.



Category: Infectious Disease

Title: New C. Diff Colitis Medication

Keywords: C. Diff Colitis (PubMed Search)

Posted: 7/16/2011 by Michael Bond, MD (Updated: 3/29/2024)
Click here to contact Michael Bond, MD

C. Diff Colitis

The general treatment recommendations for C. Diff Colitis are to place the patient on PO metronidazole and if they fail this treatment PO vancomycin (125 mg 4x day).  Vancomycin is generally reserved for resistant cases due to the fear that it could induce Vancomycin resistant enterococcus.

For severally ill patients it is recommended that you prescribe IV metronidazole and PO vancomycin when they are not actively vomiting.  Remember there is no role for IV vancomycin as it does not get into the bowel lumen to eradicate the infection.

There is some great news though, the FDA recently approved a new drug, a macrolide antibiotic fidaxomicin (Dificid), for the treatment of C. Diff Colitis. Fidaxomicin was found to be as effective as vancomycin in preventing recurrence 3 weeks after treatment.  Currently it is recommended that fidaxomicin be reserved for cases where patients are having recurrences after 3 weeks of vancomycin treatment.

The FDA news release can be found at http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm257024.htm
 



Category: Pediatrics

Title: Enterovirus Meningitis

Keywords: Enterovirus, infant, CSF (PubMed Search)

Posted: 7/15/2011 by Mimi Lu, MD (Updated: 7/22/2011)
Click here to contact Mimi Lu, MD

Now that summer is in full swing, the question is: Should the evaluation of the febrile young infant change during the summer and fall months?  And can that affect length of hospitalization and antibiotic use?

Two retrospective cohort studies from the Children’s Hospital of Philadelphia (CHOP) suggest yes!  The addition of enterovirus polymerase chain reaction (PCR) testing to cerebrospinal fluid (CSF) may improve the care of infants with fever during enterovirus season (early June through late October). 

Of note, at CHOP: 1) infants 56 days or younger routinely undergo lumbar puncture during evaluation for fever.  2) Most CSF enterovirus PCR test results (90%) were available within 36 hours; 95% of results were available within 48 hours.

In the King study, having positive enterovirus PCR CSF results decreased the length of hospitalization and the duration of antibiotic use for young infants less than 90 days, supporting the routine use of this test during periods of peak enterovirus season.  In multivariate
analysis, a positive CSF enterovirus PCR result was associated with a 1.54-day decrease in the length of stay and a 33.7% shorter duration of antibiotic use.


Bottom line: Consider adding enterovirus PCR testing to CSF obtained during the evaluation of febrile young infants during enterovirus season, as this may reduce length of hospitalization and duration of antibiotic use.  The effects, however, may be limited at institutions with slower lab turnaround times.

 

References:

1) King RL, Lorch SA, Cohen DM, Hodinka RL, Cohn KA, Shah SS. Routine cerebrospinal fluid enterovirus polymerase chain reaction testing reduces hospitalization and antibiotic use for infants 90 days or younger. Pediatrics. 2007 Sep;120(3):489-96. http://pediatrics.aappublications.org/content/120/3/489.full.pdf

2) Dewan M, Zorc JJ, Hodinka RL, Shah SS. Cerebrospinal fluid enterovirus testing in infants 56 days or younger. Arch Pediatr Adolesc Med. 2010 Sep;164(9):824-30.



Category: Toxicology

Title: Levamisole Toxicity from Adulterated Cocaine and Heroin

Keywords: levamisole, cocaine, vasculitis, agranulocytosis, heroin (PubMed Search)

Posted: 6/23/2011 by Bryan Hayes, PharmD (Emailed: 7/14/2011) (Updated: 7/14/2011)
Click here to contact Bryan Hayes, PharmD

Levamisole is an antihelminthic agent used in humans to treat certain parasitic infections and cancers.  It is more commonly used for veterinary purposes.  It has recently seen increasing use as a cutting agent for cocaine and heroin, found in up to 70% of cocaine sample seized by the DEA.  It adds bulk and weight to powdered cocaine and is even theorized to increase the stimulant effects.

Toxicity of levamisole includes agranulocytosis and vasculitis (see attached document for recent image from NEJM).

Trivia: Levamisole was found in DJ AM and Andrew Koppel (Ted Koppel’s son), who both died of drug overdoses.

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Attachments

1106231638_levamisole.doc (526 Kb)



Category: Neurology

Title: ED Management of Multiple Sclerosis Flares

Keywords: ms, multiple sclerosis, plasmapharesis (PubMed Search)

Posted: 7/13/2011 by Aisha Liferidge, MD (Updated: 3/29/2024)
Click here to contact Aisha Liferidge, MD

  • Emergency Department (ED) management of Multiple Sclerosis (MS) includes two components:

              (1) immunomodulatory therapy for the underlying immune disorder, often with high dose 

                    intravenous (IV) steroids which speeds recovery, and

              (2) management of symptoms through supportive measures and amelioration of risk factors

                    associated with precipitating acute exacerbations such as infection through aggressive use

                    of antibiotics.  Treatment of fever with antipyretics also key as even small increases in

                     temperature can significantly affect conduction through partially demyelinated fibers.

  • In patients with fulminant MS or disseminating acute encephalitis, management includes the following:
              --- Stabilize acute life-threatening conditions
              --- Initiate supportive care and seizure precautions
              --- Monitor for increasing intracranial pressure
              --- Consider emergent plasmapheresis. (may be superior to IV steroids in severe cases.  2011
                    AAN plasmapheresis guideline update reflects this assertion.)

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Hemodynamic Optimization in the Post-Arrest Patient

  • Hemodynamic instability is common in the post-cardiac arrest patient.
  • While the optimal targets remain unclear, hemodynamic stabilization often consists of intravenous fluids, vasopressors, and in rare cases mechanical support, such as an intra-aortic balloon pump or left-ventricular assist device.
  • Based on recent literature, current recommendations for mean arterial pressure (MAP) in the post-arrest patient range from 65-100 mm Hg.
  • Depending upon the baseline blood pressure and degree of myocardial stunning, many post-arrest patients will need a higher MAP (80-100 mm Hg) in order to maintain critical perfusion pressure to vital organs such as the brain.

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Category: Visual Diagnosis

Title: What's the Diagnosis? Written by Dr. Ari Kestler

Posted: 7/10/2011 by Haney Mallemat, MD (Emailed: 7/11/2011) (Updated: 8/28/2014)
Click here to contact Haney Mallemat, MD

Question

48 year old male following 15 foot fall onto both feet. What is the diagnosis?
…and why is it called the “Lover’s Fracture”?
 

Show Answer

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Category: Cardiology

Title: non-invasive ventilation in cardiogenic pulmonary edema

Keywords: non-invasive ventilation, CHF, congestive heart failure, pulmonary edema (PubMed Search)

Posted: 7/10/2011 by Amal Mattu, MD (Updated: 3/29/2024)
Click here to contact Amal Mattu, MD

There has been some controversy regarding the actual clinical benefit of non-invasive ventilation (NIV) for patients with cardiogenic pulmonary edema in recent years. However a recent Cochrane review has confirmed the benefit of NIV for these patients. Early (ED) use of NIV is associated with a decrease in both intubation rates and mortality. The NNT to prevent one intubation is 8, and the NNT to prevent one hospital mortality is 13. To put this in perspective, the NNT for NIV to prevent death in patients with cardiogenic pulmonary edema is lower than the NNT for thrombolytics to prevent death in acute MI.

One key point to remember is that it MUST be used early! If you wait until your patient is decompensating, it is often too late. Start the NIV as soon as possible in these patients.

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