UMEM Educational Pearls

Category: Toxicology

Title: Quinolone Induced Delirium

Keywords: levofloxacin (PubMed Search)

Posted: 1/21/2010 by Fermin Barrueto, MD (Updated: 12/5/2021)
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Quinolone Induced Deliurim

Just to give you another reason NOT to give a quinolone - aside from the C. diff. This adverse effect occurs with quinolones unlike many other antibiotics. It can prolong hospital stay, cause falls and further medical work ups. Some risk factors are:

  • Elderly
  • Renal Insufficiency
  • Benzodiazepine dependence (will actually precipitate withdrawal since quinolones displace the BDZ from the receptor - you have probably done this to a patient if you think about it, that may be why they went crazy)
  • Epilepsy - can cause seizures especially with NSAIDs

 


Category: Neurology

Title: Alcohol-related Seizures

Keywords: alcohol, seizure, alcohol withdrawal seizure (PubMed Search)

Posted: 1/20/2010 by Aisha Liferidge, MD (Updated: 12/5/2021)
Click here to contact Aisha Liferidge, MD

-- While we typically associate seizures within the context of alcoholism with physiologic withdrawal, studies have shown that there is a dose-dependent relationship between the consumed amount of alcohol and the onset of seizure activity, independent of alcohol withdrawal.

-- Specifically, Ng and colleagues found a 3-fold increase in seizure occurance with 50 to 100 grams of ethanol per day, compared to an 8-fold increase with 101 to 200 grams of ethanol per day.

-- This study further found that ex-drinkers (abstention for >= 1 yr.) were not at any increased risk of seizure and that drinkers who had seizures did so well outside of the conventional window of withdrawal.  

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Category: Critical Care

Title: Defining AKI

Posted: 1/19/2010 by Mike Winters, MD (Updated: 12/5/2021)
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Defining Acute Kidney Injury (AKI)

  • In the pearl from 1/5/10, I highlighted the association of AKI with increased morbidity and mortality in the critically ill along with the avoidance of nephrotoxic medications.
  • Currently, two sets of criteria (RIFLE and AKIN) can be used to identify patients with AKI
  • According to AKIN, the current diagnostic criteria for AKI is:
    • an absolute increase in serum creatinine > 0.3 mg/dL OR
    • a > 50% increase in serum creatinine from patient baseline OR
    • urine output < 0.5 ml/kg/hr for > 6 hours
  • For the critically ill ED patient, the most common causes of AKI include sepsis, hypovolemia, medications, trauma, rhabdomyolysis, obstruction and abdominal compartment syndrome

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Category: Vascular

Title: Evaluation of the acute ischemic limb

Keywords: ischemia (PubMed Search)

Posted: 1/18/2010 by Rob Rogers, MD (Updated: 12/5/2021)
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Evaluation of the acutely ischemic limb

Some considerations when evaluating/treating patients with acute limb ischemia:

  • Strongly consider anticoagulation (usually with Heparin) early
  • Consider the source of the ischemia (LV/LA thrombus, AAA mural thrombus, in situ limb thrombosis)
  • Always consider aortic dissection as an etiology of acute limb ischemia (chest pain and leg ischemia)
  • Early vascular consult and/or transfer
  • Obtain bedside ABIs on suspected cases and remember that diabetics may have normal to falsely elevated ABIs secondary to calcified vessels.
  • Common theme in laws suits for missed or delayed cases of limb ischemia: failure to perform and document ABIs

Category: Cardiology

Title: ACS and normal ECGs

Keywords: electrocardiography, acute coronary syndromes, ECG, EKG (PubMed Search)

Posted: 1/17/2010 by Amal Mattu, MD
Click here to contact Amal Mattu, MD

Most people know that the ECG is only diagnostic of ACS approximately in 50% of cases, and in fact patients presenting with ACS can have an initially completely normal ECG in up to 10% of cases. However, traditional teaching is that if the patient is actively having chest pain or other concerning symptoms, the patient with ACS will nearly always have ECG abnormalities. NOT SO, according to a recent study. Researchers from Davis medical center evaluated patients with presumed ACS and normal ECGs, comparing the prevalence of ACS in patients with active symptoms (e.g. chest pain) during the normal ECG vs. patients that were asymptomatic at the time of the ECG. Cutting to the chase, they found no difference in ther rule-in rate between the two groups. In other words, don't be reassured at all if a patients has a normal ECG during symptoms.

This study supports other studies which continually show that an abnormal ECG is excellent at ruling-in disease, but a normal ECG is poor at ruling-out disease. In the absence of a diagnostic ECG, it's all about the HPI, the HPI, and the HPI. And also...the HPI.

[Turnipsee SD, Trythall WS, Diercks DB, et al. Frequency of acute coronary syndrome in patients with normal electrocardiogram performed during presence or absence of chest pain. Acad Emerg Med 2009;16:495-499.]


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Category: Ophthamology

Title: Uveitis and Iritis

Keywords: Uveitis, Iritis (PubMed Search)

Posted: 1/16/2010 by Michael Bond, MD
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Iritis is a common diagnosis in the ED, but did you know it was actually a subset of Uveitis.

Uveitis is an inflammation of one or all parts of the uveal tract which consists of the iris, the ciliary body, and the choroid.
 
The subsets of uveitis are:

  1. anterior
  2. confined to the iris and anterior chamber -- iritis
  3. confined to the iris, anterior chamber, and ciliary body -- iridocyclitis.
  4. Posterior uveitis -- choroiditis and chorioretinitis, is uncommon, with the exception of cytomegalovirus (CMV) retinitis in patients with AIDS.


Treatment of iritis and uveitis next week.

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Pediatric Constipation is a common presentation to PED and large percentage of GI clinic patient volume

Defined as less than 2 stools per week for two weeks with hard, large pellet like stools

Broad Differential includes functional constipation (most common), stricture, obstruction, celiac disease, Hirschsprung, hypothyroid, Cow's milk protein allergy, CF and spina bifida.  Always inspect the spine and perform rectal

Success of treatment is based on the aggressive nature of treatment and timing of treatment.  Ttreatment is longer and more difficult if patient has to wait on referral to GI specialist.

  • Clean out with enema and stool softener (miralax BID for two days, followed by daily maintenance regimen is most common)
  • Cheaper and effective regimens include mineral oil, kondremul or lactulose
  • Encourage behavioral therapy with routine toilet time and rewards
  • Increase fiber in diet to 8-10 grams for toddlers, 12-14 preschool and 14-16 for school age
  • Initial treatment is safe and does not require electrolyte monitoring.
  • Failed treatment and bounceback may require GI consult, inpatient Golytely therapy with electrolyte monitoring

Category: Toxicology

Title: Anion Gap Metabolic Acidosis

Keywords: anion gap, metabolic acidosis (PubMed Search)

Posted: 1/14/2010 by Bryan Hayes, PharmD (Updated: 1/15/2010)
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As we are now into the winter months, exposures to ethylene glycol (antifreeze) and methanol (windshield washer fluid) increase.  Here is a good mnemonic for sorting through an anion gap metabolic acidosis:

C – cyanide, carbon monoxide
A – alcoholic ketoacidosis, acetaminophen (massive OD)
T – toluene (chronic from glue sniffing)
M – methanol, metformin
U – uremia
D – diabetic ketoacidosis
P – propofol infusion syndrome, propylene glycol, paraldehyde
I – iron, isoniazid, ibuprofen (massive OD)
L – lactic acidosis
E – ethylene glycol
S – salicylates, starvation ketoacidosis


Category: Neurology

Title: Stroke-related Seizures

Keywords: stroke, seizure (PubMed Search)

Posted: 1/13/2010 by Aisha Liferidge, MD (Updated: 1/15/2010)
Click here to contact Aisha Liferidge, MD

  • While seizure is rarely associated with stroke during its hyperacute phase, Arboix found that the development of epileptic strokes within the first 48 hours post-stroke occurs about 2.4% of the time and portends a higher degree of in-patient mortality.
  • Seizure activity in the setting of acute stroke is more commonly associated with hemorrhagic types (4.3 % of cases), compared to just 2% with ischemic strokes.
  • Younger age, acute confusional states, hemorrhagic strokes, cortical strokes, and strokes affecting the frontal, parietal, occipital, and temporal lobes were found to be risk factors for stroke-related seizures.
  • The use of prophylactic anti-epileptic medication in the acute phase of stroke varies and, some say, requires further research; such treatment is more commonly reserved for use in hemorrhagic stroke patients, however, if at all.

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Category: Critical Care

Title: Sepsis Definition

Posted: 1/12/2010 by Evadne Marcolini, MD (Updated: 12/5/2021)
Click here to contact Evadne Marcolini, MD

The term Sepsis is frequently and colloquially used to describe "sick" patients; but accuracy requires understanding the specific criteria of Sepsis and its associated syndromes.  Following are the defining criteria for SIRS and Sepsis:

SIRS

at least 2 of the following:

Temp >38C or <36C

Heart rate >90

RR> 20 or pCO2<32mm Hg

WBC>12,000, <4,000 or >10% bands

 

Sepsis:

Systemic response to infection, manifested by 2 or more SIRS criteria with a source of infection confirmed by culture or a clinical syndrome pathognomic for infection.


Severe Sepsis:

Sepsis associated with acute organ dysfunction, hypoperfusion or hypotension; including lactic acidosis, oliguria or altered mental status.


Septic Shock:

Sepsis-induced hypotension not responsive to fluid resuscitation.

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Category: Airway Management

Title: Altered Mental Status-Some Can't Miss Diagnoses

Keywords: Altered mental status (PubMed Search)

Posted: 1/11/2010 by Rob Rogers, MD (Updated: 12/5/2021)
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Altered Mental Status-Three Diagnoses That Can "Bite You On The Buttocks"

When evaluating the patient who is altered, consider the following diagnoses:

1. DTs-seems simple enough, right? Remember that some altered patients will not be able to give a history of alcoholism. And this is definitely a diagnosis that can sneak up on you. Bottom line: consider DTs in ALL patients with a delirium.

2. Wernicke's encephalopathy-can also be very difficult to detect. Consider in ALL alcoholic patients with altered mental status and give Thiamine. 

3. Herpes encephalitis-speaking from personal experience, this diagnosis can be extremely tough to diagnose. Consider giving emperic Acyclovir in patients with WBCs in their CSF and a negative gram stain. And don't forget to send off a Herpes PCR. As far as clinical presentations, CNS Herpes can present with a wide spectrum of findings, from isolated headache, to new psychobehavioral changes, to severe depression of consciousness and coma. Be aware that this diagnosis isn't common but failure to initiate Acyclovir may be a fatal mistake. 


Category: Cardiology

Title: therapeutic hypothermia in STEMI patients with cardiac arrest

Keywords: Acute myocardial infarction, acute MI, cardiac arrest, STEMI, hypothermia, therapeutic hypothermia (PubMed Search)

Posted: 1/10/2010 by Amal Mattu, MD (Updated: 12/5/2021)
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Though most people know that therapeutic hypothermia is indicated in resuscitated victims of cardiac arrest, is it safe if that cardiac arrest victim is also being treated for STEMI? Do you need to worry about increased bleeding complications in these patients that are receiving anticoagulants, lytics, PCI, or other standard "bleeding" medications? Are these patients at increased risk for hemodynamic instability with therapeutic hypothermia?

Recent studies have demonstrated that therapeutic hypothermia in acute MI patients receiving other standard treatments (i.e., anticoagulants, etc.) is SAFE: it is associated with no increase in bleeding complications (1), no increase in time to balloon inflation (2), and no increase in hemodynamic instability or malignant arrhythmias (3).

1. Schefold JC, et al. Mild therapeutic hypothermia after cardiac arrest and the risk of bleeding in patients with acute myocardial infarction. Int J Cardiol 2009;132:387-391.
2. Knafelj R, Radsel P, Ploj T, et al. Primary percutaneous coronary intervention and mild induced hypothermia in comatose survivors of ventricular fibrillation with ST-elevation acute myocardial infarction. Resuscitaiton 2007;74:227-234.
3. Wolfrum S, Pierau C, Radke PW, et al. Mild therapeutic hypothermia in patients after out-of-hospital cardiac arrest due to acute ST-segment elevation myocardial infarction undergoing immediate percutaneous coronary intervention. Crit Care Med 2008;36:1780-1786.


Category: Orthopedics

Title: Paronychia

Keywords: Paronychia (PubMed Search)

Posted: 1/9/2010 by Michael Bond, MD
Click here to contact Michael Bond, MD

Acute paronychia

  • Usually result from minor trauma of the skin around the fingernail such as biting, manicures, picking a hangnail or finger sucking.
  • Staphylococcus aureus is the most common infecting organism. However other mouth flora such as Streptococcus and Pseudomonas species, gram-negative bacteria, and anaerobic bacteria can also be a cause.
  • Recommended treatement consists of incision and drainage and placing the patient on  amoxicillin /  clavulanic acid or clindamycin to cover all the organisms noted above.

Category: Pediatrics

Title: Hyperleukocytosis / Blast Crisis

Keywords: hyperleukocytosis, leukemia, blast crisis (PubMed Search)

Posted: 1/8/2010 by Adam Friedlander, MD (Updated: 12/5/2021)
Click here to contact Adam Friedlander, MD

 

Hyperleukocytosis is often seen in acute presentations childhood leukemias, and is defined as a WBC count of greater than 30-50K.  Complications usually arise at counts greater than 300, however, keep in mind that automated cell counters may underestimate very high white counts.

Complications include:

  • Hyperviscosity Syndrome / Leukostasis
    • Risk of CVA, PE, Mesenteric Ischemia, etc.
  • Tumor Lysis Syndrome (TLS)
    • Risk of fatal arrhythmia, may monitor with K, LDH, Uric Acid
  • Disseminated Intravascular Coagultion (DIC)

Treatment:

  • EMERGENT LEUKOREDUCTION APHERESIS, aka Leukopheresis
  • This is a true emergency - if you are at a facility without leukopheresis capability, the fastest transport mode possible is indicated - fly, don't drive
  • Temporizing measures include fluids, fluids, and fluids
  • Allopurinol / Rasburicase may be considered, but not if this will delay transport, especially if there is no evidence of TLS - this decision may be made in consultation with the pediatric heme/onc specialist who is helping to arrange for leukopheresis

Category: Toxicology

Title: ANTIDOTES: DMSA

Keywords: DMSA, succimer, lead, arsenic, mercury (PubMed Search)

Posted: 1/7/2010 by Ellen Lemkin, MD, PharmD (Updated: 12/5/2021)
Click here to contact Ellen Lemkin, MD, PharmD

SUCCIMER (DMSA)

  • An oral agent used for the chelation of heavy metals, such as LEAD, ARSENIC and MERCURY
  • Forms a water soluble agent that chelates the heavy metal, which are renally excreted
  • Most common side effects are rashes, urticaria and GI
  • A serious adverse effect is neutropenia, which is rare

Category: Neurology

Title: cortical vs. subcortical strokes

Keywords: stroke (PubMed Search)

Posted: 1/6/2010 by Aisha Liferidge, MD (Updated: 12/5/2021)
Click here to contact Aisha Liferidge, MD

Cortical versus Subcortical Strokes

  • Gray matter (neuronal cell bodies) of the brain forms a rim over the cerebral hemispheres, forming the cerebral cortex.
  • White matter (neuronal axons coated in myelin) is located below the cortex and makes up the "subcortical" regions of the brain.
  • Strokes affecting the cerebral cortex (i.e. cortical strokes) classically present with deficits such as neglect, aphasia, and hemianopia.
  • Subcortical strokes affect the small vessels deep in the brain, and typically present with purely motor hemiparesis affecting the face, arm, and leg.
  • Nearly 30% of all ischemic strokes are subcortical in nature, and includes lacunar infarcts which have the best prognosis.


---------------------------------------------------------------------------------------------------------------------------
 
Aisha T. Liferidge, MD, FACEP
---------------------------
Assistant Professor, Attending Physician
University of Maryland School of Medicine
Department of Emergency Medicine
Baltimore, MD 21201
----------------------------
MPH Candidate, Columbia University 2011


Category: Critical Care

Title: AKI and the Critically Ill

Posted: 1/5/2010 by Mike Winters, MD (Updated: 12/5/2021)
Click here to contact Mike Winters, MD

AKI and the Critically Ill

  • Acute kidney injury (AKI) is an abrupt reduction in kidney function causing disturbances in electrolytes, fluids, and acid-base balance.
  • AKI occurs in up to 67% of critically ill patients and is associated with a substantial increase in morbidity and mortality.
  • AKI in the critically ill is often multifactorial and most commonly due to sepsis, hypovolemia, medications, and hemodynamic instability.
  • Medications account for up to 20% of AKI in the critically ill.
  • Common medications that cause, or exacerbate AKI, in the critically ill include:
    • NSAIDS
    • Antibiotics (aminoglycosides, amphotericin, acyclovir)
    • ACE-inhibitors
    • Radiocontrast dye
  • Take Home Point:  AKI is common in our critically ill ED patients and, whenever possible, avoid nephrotoxic medications that can result in additional injury.

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Category: Cardiology

Title: medications in cardiac arrest

Keywords: ACLS, ALS, advanced cardiac life support, cardiac arrest (PubMed Search)

Posted: 1/3/2010 by Amal Mattu, MD (Updated: 1/5/2010)
Click here to contact Amal Mattu, MD

  Despite the traditional use of intravenous medications such as vasopressors and antiarrhythmics for victims of cardiac arrest, there is actually very little evidence to support these therapies. On the contrary, 2 recent multicenter center studies demonstrated that the use of intravenous medications that are advocated in standard advanced cardiac life support (ACLS) guidelines are ineffective at improving survival to hospital discharge of patients with primary cardiac arrest. In contrast, these medications have been shown to increase hospital admissions, bed and resource utilization, and costs. The only interventions that have been shown to improve meaningful outcomes are rapid defibrillation for shockable rhythms, good compressions, post-resuscitation therapeutic hypothermia, and there's increasing evidence for post-resuscitation cardiac catheterization as well.

In other words, the best thing you can do early for patients with primary cardiac arrrest is to focus on the basics.

 

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Category: Dermatology

Title: Pityriasis Rosea

Keywords: Pityriasis rosea (PubMed Search)

Posted: 1/3/2010 by Michael Bond, MD
Click here to contact Michael Bond, MD

Pityriasis Rosea

  • A common exantham that typically presents initially with a herald patch, followed by a generalized rash over the next 1-2 weeks and can last 4-6 weeks.
  • Patients may initially have prodromal symptoms such as joint pain,headache, fever and malaise that precede the appearance of the rash.
  • The primary plaque, herald patch, is seen on the skin in 50-90% of cases.
  • The generalized rash typically develops in crops along the lines in the skin leading to a characteristic "Christmas tree" pattern.
  • Pruritus is present in 75% of cases.
  • Usually a self-limited, benign illness that does not require any treatment.  Though symptomatic treatment of the pruritus is reasonable.

Category: Pediatrics

Title: Meningitis Prophylaxis and Child Care

Keywords: meningitis, neisseria meningitidis, streptococcus pneumoniae, haemophilus influenzae, child care, nursery (PubMed Search)

Posted: 1/1/2010 by Heidi-Marie Kellock, MD (Updated: 12/5/2021)
Click here to contact Heidi-Marie Kellock, MD

Meningitis Prophylaxis in Children

While H1N1 and garden-variety influenza have been taking the spotlight lately, we can't forget about other disease processes.  Meningitis is still a severe, life-threatening/altering process which occurs in various social groups (e.g. military cadets, college students).

However, with more of our parents working out of the home, child care is more often the norm, and as such, you may find yourself dealing with cases of children who have been in proximity to another child or caregiver diagnosed with meningitis.  What do you do?

The causative agent will often dictate your choice of management.

Neisseria meningitidis - nursery/child care contacts should receive chemoprophylaxis and the Menactra vaccine (if they have not already received it) within 7 days of onset;  casual school or work contacts do NOT require prophylaxis

Streptococcus pneumoniae - no chemoprophylaxis or vaccination required (unless series was not continued)

Haemophilus influenzae - if only one case reported, no intervention;  if 2 or more cases within a 60-day period, Hib vaccination and chemoprophylaxis with rifampin for BOTH children and caregivers (especially if the center cares for young children who have not completed their Hib series)

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