UMEM Educational Pearls

IV acetaminophen has been approved for use since November 2010

It is indicated for the:

• Treatment of mild to moderate pain
• Combination therapy with opioids for treatment of moderate to severe pain
• Fever reduction

The results of studies demonstrating opoid sparing effects have been mixed; some studies have not demonstrated either a reduction in opioid dose or opioid side effects.

The dose is the same for acetaminophen administered by other routes.

It must be administered over 15 minutes, and onset of activity is 15 minutes. Peak effect occurs at one hour.

The MAJOR drawback is the cost, which is $13 dollars per vial. This is compared to oral acetaminophen and ibuprofen, which are pennies.

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Lithium Toxicity

• Lithium toxicity is common and occurs in 75 to 90% of patients receiving long-term lithium therapy at some point during their management.  It most often results from inadequate renal excretion.
• Toxic patients typically present with mild side effects such as hand tremor, but other symptoms like weakness, delirium, rigidity, hyperreflexia, altered gait, seizure, and EEG changes may also result.
• While severe lithium toxicity typically correlates with elevated serum levels, not all patients with high lithium levels present with advanced symptoms, at least in the early stages; this is due to delayed distribution within tissues.  Similarly, patients with lower serum levels of lithium may present with advanced symptoms, if the drug has accumulated in the cerebrospinal fluid to a greater extent than it has the serum. 

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Gastrointestinal Changes of Obesity that Complicate Critical Illness

• Obesity predisposes patients to several gastrointestinal abnormalities that can cause, or complicate, critical illness.
• Important abnormalities to keep in mind when managing a critically ill obese patient include:
  • Increased intra-abdominal pressure which predisposes to abdominal compartment syndrome
  • Increased incidence of nonalcoholic fatty liver disease which may lead to prolonged drug metabolism
  • Increased incidence of cholelithiasis which may result in pancreatitis or cholangitis

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I found this neat little pearl on Michelle Lin's blog, Academic Life in Emergency Medicine, and thought it was worth sharing with everyone:

"In my theme of detoxifying malodorous smells in the ED (see Toxic Sock Syndrome and abscess drainage), I recently learned of a new way of masking odors. Imagine the stress on your olfactory nerves from the combined effects of urinary and fecal incontinence from a nursing home patient.

An ingenious nurse proposed nebulizing actual coffee within the room. Unfortunately, our ED was out of coffee at the moment.

Trick of the Trade:
Nebulized orange juice

I only learned of this trick after walking into the patient's very subtly foggy room. About 4 cc of orange juice had been nebulizing for a few minutes. The room smelled a little like a Jamba Juice (a smoothies/ juice shop). Quite pleasant actually. I was shocked to find that it masked the odors quite well."

Thanks for the tip, Michelle. Freshly-squeezed anyone??

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Cocaine-associated MI occurs fairly early after acute cocaine use. 50% of MIs occur in patients prior to their arrival in the ED, and 24% of the total will occur within the first hour of cocaine use. If a patient has not ruled in by 12 hours post-arrival in the ED, it is extremely unlikely that the patient will rule in or suffer ACS-related complications from the cocaine....thus the concept behind using rapid rule out protocols in these patients.

The most important thing we as physicians can do for these patients is to strongly emphasize discontinuation of cocaine use and refer to rehab whenever possible. If the patient discontinues using cocaine, the prognosis for absence of subsequent cardiac events is excellent.

[thanks to Dr. Ellen Lemkin for her contribution to this pearl}

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Tendon Lacerations:

Hand lacerations need to be carefully explored in order to determine whether there is an associated tendon laceration.  These can be be difficult to find unless a systematic approach is followed:

• The laceration should be explored to its base in a bloodless field while the fingers and wrist are moved through their full range of motion (ROM).  A tendon laceration can easily be missed if the hand is only visualized with the fingers extended. The area of the tendon that was lacerated can retract into the hand, or not be visible if the area was injured when the fingers were flexed. By extending the finger, the location of the injury may not line up with the wound making it impossible to see unless the fingers are moved through their full ROM.
• The fingers and wrist ROM should be tested actively and against resistance as the patient may only experience an increase in pain and have a completely normal ROM if there is only a partial tendon laceration.
• If there is a suspicion of a tendon laceration (decreased ROM, or increased pain with resistance when ROM is tested) the laceration may need to be extended in order to completely visualize the tendon if it can not be done through the wound that was created with the original injury.

Future pearls will cover techniques on how to repair tendon lacerations.  Stay tuned.

You decided to intubate a child and wisely remembered that you should also follow with an NG/ OG after intubation to decompress the stomach.  In order to avoid the blank stare when asked "what size"?  Here's a nice mneumonic about Pediatric "tube" sizes... easy as 1-2-3-4!!!  Please note ETT = endotracheal tube size.

• 1 x ETT = (age/4) + 4 (formula for uncuffed tubes)
• 2 x ETT = NG/ OG/ foley size
• 3 x ETT = depth of ETT insertion
• 4 x ETT = chest tube size (max, e.g. hemothorax)

So for example, a 4-year-old child would get intubated with a 5-0 ETT inserted to depth of 15 cm (3x ETT), a 10Fr NG/OG/foley (2x ETT), and a 20Fr chest tube (4x ETT).

Also, remember that you can use cuffed tubes in any child except neonates but the formula needs to be adjusted as follows: cuffed endotracheal tube ID (mm) = (age/4) + 3.5

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Treating a patient with clinical hypoglycemia (neuroglycopenia if you want to sound cool) is with "1 amp of D50". Then some are starting D5 drips and D10 drips. Here is the actual breakdown of what you are giving:

1 amp of D50 = 50% dextrose = 50g/100mL = 25g x 4Kcal/g carbs = 100 calories bolus

1 L D5W at 100mL/hr = 5% Dextrose = 5g/100mL x 1L = 50g x (4Kcal/g) = 200 cal infusion of 20 cal/hr!

1 L D10W at 100mL/hr = 10%D= 10g/100mLx1L= 100g x (4Kcal/g)= 400 cal at infusion of 40 cal/hr!

Snickers Bar = 271 calories in one serving - most people will eat in 5 minutes =  54.2cal/min

Take home message is feed your patient once they are awake and alert. Much more effective.

Contraindications to performing lumbar puncture (LP):

- INR > 1.4 or other coagulopathy

- Platelets < 50

- Infection at desired puncture site

- Obstructive / non-communicating hydrocephalus

- Intracranial mass

- High intracranial pressure (ICP) / papilledema (relative contraindication depending on etiology; especially a concern with intracranial mass lesion secondary to the increased risk of transtentorial or cerebellar herniation)

- Focal neurological symptoms/signs, decreased level of consciousness

- Partial / complete spinal block

- Acute spinal trauma

A mortality benefit from combination antimicrobial therapy has not been clearly demonstrated in sepsis. However, when only the most severely-ill patients (i.e., septic shock) are considered in subgroup analysis, there appears to be a mortality benefit to using two antimicrobials against a suspected organism.

Combination antimicrobial therapy may reduce mortality through three mechanisms.

1. Increased probability that the causative organism will respond to at least one drug. 
2. Preventing emergence of antimicrobial resistance.
3. Two antimicrobials may act synergistically.

Always obtain appropriate cultures before initiating therapy. Although identification and susceptibility of the organism may take some time, eventually narrowing antimicrobial therapy to monotherapy in the ICU is still recommended. 

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Question

Patient presents with the following X ray after yawning. Diagnosis?

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Traditional teaching for many years has been that new or presumed new LBBB in patients with anginal type of symptoms should be treated as a STEMI, i.e. with immediate PCI or lytics. However, that teaching is based on poor evidence. Newer, increasing evidence is suggesting that new/presumed new LBBB in patients with anginal symptoms is actually not associated with acute MI any more often than when a patient has an old LBBB with those symptoms.

Probably the best management in patients with anginal type of symptoms and a new/presumed new LBBB is to contact the cardiologist on call and ask them for their preference in terms of treatment. Those patients are not necessarily definite AMIs.

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Gout treatment considerations

Treatment is directed to relieve pain and inflammation

NSAIDs, steroids and narcotics are the mainstays of treatment. All 3 should be used in combination.

Aspirin should be avoided as it may increase uric acid levels

     Note: not in prevention doses (81mg) in treatment doses (325-650mg q4h)

      NSAIDs and steroids take time to be effective.  Provide appropriate analgesia with oral narcotic medication for short term relief

     Don't forget the benefit of splinting a "hot" joint (the ankle or wrist for example)

NSAIDs: Use may be limited in the elderly and in those on coumadin or with peptic ulcer disease. 5-7 days of treatment is usually sufficient. Indomethacin is most commonly used (50 mg TID, which may be tapered to 25 mg TID after 3 days)

Steroids:  Likely more effective than NSAIDs. Oral prednisolone is more effective than naproxen (1). Use prednisone 30-50 mg for 3-5 days without tapering (as we use for asthma). May be useful to supplement with NSAIDs on the tail end to prevent a rebound flare. If tapping the joint consider intraarticular steroids. If there is concern for medical noncompliance with oral steroids consider IM steroids (triamcinolone 60mg or methylprednisolone).

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The ability to determine whether or not a patient is an alcoholic or will go into alcohol withdrawal syndrome (AWS) is not amenable to a clinical decision rule though many attempts have been made. The strongest predictor that a patient can develop AWS is a positive family history of AWS. Some clinical and biochemical predictors are:

ALT >50 U/L

K <3.6

These two in one study have had an odds ratio of 9.0 and 5.7 respectively though specificity was quite low. Ethanol levels has also found to be contradictory. Being able to predict AWS does not currently seem plausible but the treatment of AWS should and can involve a clinical decision rule like CIWA-Ar which is a scoring system that takes into account N/V, tremor, sweats, anxiety, agitation, hallucinations, headache and sensorium. Take a look at the scoring system that is most validated and utilized for symptom triggered therapy - often considered the most effective treatment for alcohol withdrawal.

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Attachments

1104212257_CIWA-Ar.pdf (10 Kb)

• Patient positioning is key when measuring opening pressure (OP) of cerebrospinal fluid (CSF) during lumbar puncture. 

• OP is only accurate when measured while the patient is completely horizontal and relaxed, in the lateral decubitus position (i.e. no neck flexion or extension, legs extended, no valsalva).  In order to achieve this, you may need to carefully place patient in a lateral decubitus position if they are initially sitting upright prior to dural puncture and/or be sure to have patient straighten their legs (i.e. abort fetal position) once ready to measure OP.

• Strictly speaking, normal range of CSF pressure is 8 to 21 cm, but obesity can increase it up to 25 cm and still be considered normal.  Thus, while the significance of measurements between 20 and 25 cm in obese patients may be unclear, levels above 25 cm are always abnormal.

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Combination Antimicrobial Therapy for Gram (+) Bacteremia

• Bacteremia is a major cause of morbidity and mortality in the critically ill patient.
• S.aureus remains a common isolate in patients with either hospital-acquired or community-acquired bacteremia.
• In cases of suspected endocarditis due to S.aureus, traditional teaching has been to give an aminoglycoside (i.e. gentamicin) in combination with vancomycin or an antistaphylococcal penicillin.
• Importantly, there is no strong evidence to support this combination in patients with suspected S.aureus bacteremia.
• Furthermore, patients receiving the aminoglycoside combination have higher rates of renal impairment without any added clinical benefit.

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Dabigatran is a new oral anticoagulant (direct thrombin inhibitor) which is being marketed as the new drug to replace warfarin in many cardiac patients. You'll hear much more about it in the coming year, but for now you should know the main advantage and disadvantage:
1. advantage: no need to check levels, e.g. INRs
2. disadvantage: no reversal agent; if a patient is actively bleeding, all you can do is to hold further doses and provide supportive therapy, e.g. tranfusions; hemodialysis is another option, but not ideal to place new dialysis catheters emergently in patients that are coagulopathic!

This second point, the disadvantage of having no reversal agent, is potentially a big issue, especially in older patients at risk for falls. Stay tuned for more information...

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Gout Part 2

• Hyperuricemia can result from both uric acid overproduction (metabolic/myeloproliferative diseases) in addition to uric acid underexcretion (more common).
• Consider gout in any patient who complains of joint pain that reaches peak intensity over hours and may wake them from sleep. Septic joints tend to reach peak intensity of days.
• Patients may have multi joint involvement, low-grade fever and leukocytosis (factors that may lead one to consider an alternative diagnosis)
• Remember that gout is also a disease of the synovial tissue (tendonitis and bursitis).
• NSAIDs: Traditional preferred treatment for acute gout
• Colchicine: Less effective if the current attack is >24 hours. Use correct dosage for best effect/side effect ratio.
• Steroids: At least as effective as NSAIDs.

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Kiwi fruit and latex share several antigens in common.  Thus, individuals who are allergic to either kiwi or latex may also suffer hypersensitivity reactions to the other material.

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• Chemoprophylaxis should be given to those individuals who came into "close contact" with someone infected with meningitis due to meningococcal infection (i.e. Neisseria meningitidis).  It should be given as early as possible following the exposure; when there is a high index of suspicion, do not wait for culture results to give prophylaxis.
• Chemoprophylaxis is generally not indicated when the etiology is Streptococcus pneumoniae, and should be reserved for young children who have not received a Haemophilus influenzae type b (Hib) vaccination and immunocompromised close contacts when the etiology is Hib.
• While the definition of a "close contact" remains somewhat ambiguous, it generally refers to individuals who have had prolonged (>8 hours) contact while in close proximity (<3 ft) to the patient, or who have been directly exposed to the patient's oral secretions between one week prior to the onset of the patient's symptoms until 24 hours after initiation of appropriate antibiotic therapy.
• Standard regimens for antimicrobial prophylaxis include ciprofloxicin, ceftriaxone, and rifampin.  Adults typically require a single oral dose of 500 mg of ciprofloxicin or 250 mg of intramuscular (IM) ceftriaxone, while individuals under age 15 may receive a single dose of 150 mg of IM ceftriaxone.

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