UMEM Educational Pearls

• Seizure is very rarely associated with true ischemic stroke; the presence of seizure is, in fact, a  contraindication for administering t-PA in patients thought to have had a stroke.

• Thus, when patients present with an alleged stroke in the setting of seizure, be skeptical as to whether there truly was an ischemic stroke and do more investigating to ascertain a satisfactory conclusion.  In these cases, perhaps the patient suffered a hemorrhagic stroke, which is associated with seizure more often than is ischemic stroke.

• Post-seizure sequelae can present as focal neurologic deficit that mimics stroke (i.e. Todd's Paralysis), but note that these are generally associated with partial, not generalized, seizures.

• Finally, remember that patients who have had strokes in the past are at increased risk for having future strokes AND for developing a seizure disorder secondary to the focal area of brain tissue damaged by their prior stroke.  These patients, therefore, may present with a combination of true, new OR exacerbated, old stroke symptoms, with or without seizure.

The optimal hemoglobin concentration during critical illness is unknown. Although a liberal transfusion strategy (Hb 10-12 g/dL) was once believed to be beneficial for hemodynamics, evidence suggests targeting a conservative strategy (Hb 7-9 g/dL) does not increase mortality, while the unnecessary transfusion of blood products can cause harm (transfusion associated lung injury, infection, etc.) in the non-hemorrhaging patient. 

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Question

44 y/o female restrained driver s/p motor vehicle crash complaining of chest pain and shortness of breath. 

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Dabigatran (Pradaxa), an antithrombin medication, was discussed in an earlier pearl and thought I would play devil's advocate and explain the possible concerns:

• Yes you don't need INRs to evaluate therapeutic levels but the problem is also don't know if its subtherapeutic or supratherapeutic. This can be an issue during times of transition fromLWMH or coumadin. There are specific protocols to follow for "bridging".
• Though not clinically significant, there was an increase in myocardial infarction in thedabigatran (Pradaxa) group when compared to coumadin - remember vioxx?
• FDA approved dabigatran for stroke prevention, embolism, in AF patients. Though people will automatically translate all of the indications coumadin has that cannot be done yet.
• No reversal agent so in an acute (ED) setting, you are in trouble and are depending on the relatively short half-life to get you out of trouble.

Toxicology Mantra: You never want to be the first person or the last person to use a drug

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Valproic Acid in Status Epilepticus

• In previous pearls, we have discussed the treatment of status epilepticus (SE) with first-line (benzodiazepines) and second-line agents (phenytoin/fosphenytoin).
• Refractory SE is defined as the failure to respond to both first- or second-line antiepileptic medications.
• Valproic acid is listed in many algorithms as a third-line agent for treating SE.
• Avoid valproic acid in refractory SE patients who have hepatic disease or dysfunction.
• Although rare, valproic acid can cause a fatal hepatotoxicity in these patients. 

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Well, there may finally be a replacement for patients with atrial fibrillation who take warfarin (Coumadin).

In late 2010, the FDA approved the drug Dabigatran (Pradaxa) for use in patients with atrial fibrillation.

Dabigatran is an oral direct thrombin inhibitor that has been approved for stroke prevention in patients with A Fib. The drug does not need monitoring like warfarin, and has been deemed to be safer than warfarin.

Be on the lookout for Dabigatran...

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Bretylium was touted for many years as the drug of choice for patients with ventricular dysrhythmias in the setting of hypothermia...in fact it still is recommended by some. Bretylium was actually touted to be effective based on animal studies in which the dogs were PRE-treated with bretylium and then hypothermia was induced. It was found that dogs that were pretreated had fewer episodes of ventricular fibrillation than dogs that were not pretreated. On the other hand, if bretylium was used as a treatment for VFib rather than a prophylactic, it was ineffective. The bottom line....don't bother with bretylium.

Iliotibial band syndrome (ITBS)

• Due to recurrent friction of the iliotibial band (ITB) sliding over the lateral femoral condyle.


http://footcarexpress.com/foot-orthotics/wp-content/uploads/2009/01/iliotibial-band-syndrome.jpg


Hx -

• Sharp or burning pain on the lateral aspect of the knee usually in runners.

• Rarely occurs at start of run, rather, occurs after reproducible time or distance
• (especially when running downhill)


PE-

• Typically negative other than local tenderness (approx. 2cm above lateral joint line) & occasional swelling over the distal ITB.
• 
Specialized tests: See also Ober's test and Noble's test

• 
http://www.youtube.com/watch?v=A0C0WBw4l4s

• http://www.youtube.com/watch?v=IIJVbf_t_2A


Tx

• Most patients respond to conservative treatment involving NSAIDs, stretching of the iliotibial band, strengthening of the gluteus medius, and altering training regimens.

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• Parkinson's Disease is a degenerative disorder of the central nervous system characterized by tremor and impaired muscular coordination due to deficient levels of intra-cerebral dopamine.
• Many of these patients experience motor fluctuations which consists of periods of being "on," which is when they experience a good or hyper response to their medication, and periods of being "off," which is when the parkinson's condition itself is exacerbated.  Differentiating between these two modes is important in terms of managment, but may be challenging.  
• "On time" typically presents with relatively normal or dyskinetic involuntary  ballistic movements, chorea, dystonia, or myoclonus.  These episodes are best treated by avoiding levodopa, carefully administering low-dose benzodiazepines, or perhaps amantadine(possibly effective).
• "Off time"typically presents with sometimes painful dystonia, intorsion of limbs, spasm, and stiffness, and often relates to a period wherein the effects of parkinson's medications such as levodopa are wearing off.   These episodes are best treated by gradually increasing dopamine agonist medication such as bromocriptine, pramipexole, and ropinirole, and likely admission to the hospital. 

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Boxer's (or Brawler's) Fracture

• Fifth metacarpal neck fracture, usually secondary to a direct blow or closed-fist impact.
• Potentially an unstable fracture and difficult to maintain reduction due to tension from tendons and muscles in the hand.
• Up to forty degrees of angulation can be tolerated without repair, although there is potential for reduced hand function without repair. Any rotational deformity, however, must be corrected.
• Non-displaced fractures: RICE therapy, gutter splint, and Ortho follow-up.
• Displaced, rotated, or angulated fractures (>40 degrees): closed reduction may be attempted but surgical fixation usually required.

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Up to 30-40% of patients with infective endocarditis have neurological symptoms as a result of embolization. This is a good reminder of the frequency of embolization, and also that infective endocarditis should always be part of the differential when you are evaluating a patient with fever + neurological abnormalities.

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FARES Method for Reduction of Anterior Shoulder Dislocations.

This method that was recently highlighted in a publication had a ~78% success rate with the authors able to reduce the shoulder in an average of 2.36 ±1.24 minutes  without having to give the patients any analgesics or sedatives. The technique is done by:

• Placing the patient in the supine position.
• Hold the hand of the affected arm while the arm is at the patient’s side with the elbow extended and the forearm in neutral position.  
• Apply gentle longitudinal traction and slowly move the arm into abduction while oscillating the forearm with continuous, brief (two to three full cycles per second) and short range (approximately 5 cm above and beneath the horizontal plane) vertical  movements of the arm.  These oscillations should be done during all   all stages of the reduction as it helps that patient relax their muscles.
• Once the arm is abducted past 90º, gently externally rotate the arm while continuing to abduct it.  Continue the oscillations.
• Reduction is usually achieved at ~ 120º of abduction.  
• Once reduction is achieved, move the arm gently until it is internally rotated and resting on the patients chest.

Consider trying this with your next shoulder dislocation.  No single method of reduciton is 100% successful, but methods like this that only require a single provider and do not require analgesics are extremely helpful in improving patient flow as they do not utilize a lot of ED resources..

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The Rumack-Matthew nomogram is a well studied and validated tool to help assess the potential for liver toxicity following acute acetaminophen poisoning.  Here is a brief review of when it is best utilized.

• Prior to 4 hours post-ingestion: Not helpful to determine likelihood for toxicity.  Only use is to confirm an ingestion took place.
• Between 4 and 24 hours post-ingestion: Plot the patient's level vs. time after ingestion.  If above the toxicity line, treat with acetylcysteine.
• More than 24 hours post-ingestion: Any elevated acetaminophen level is toxic and should be treated with acetylcysteine.

Outside-the-box situations:

• Chronic exposures: Nomogram not indicated.
• Overdoses with co-ingestants that slow GI motility (e.g., opioids, diphenhydramine) OR extended release products (e.g., Tylenol Arthritis): If the level at 4 hours post-ingestion is not toxic, repeat it at 8 hours post-ingestion.  If either level is toxic, treat with acetylcysteine.

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• Using the neurological examination to test coordination primarily assesses cerebellar function.
• The cerebellum is important for motor learning and timing of motor activity.  It fine-tunes agonist and antagonistic forces of muscle activity, simultaneously and sequentially, across multiple joints which results in smooth and purposeful movements.
• Cerebellar dysfunction causes deterioration of movements, with subsequent under-shooting and over-shooting of purposeful movement, also known as dysmetria.
• Deterioration of movement and dysmetria are precursors to the development of ataxia.

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Dexmedetomidine for Sedation in Acute Neurologic Disease

• Critically Ill patients with acute neurologic disease are managed daily in the ED.
• Due to the need for frequent neurologic assessments, these patients can be challenging should they require sedation.
• Dexmedetomidine, a selective alpha-2 adrenergic receptor agonist, has emerged as an alternative to traditional sedatives (i.e. opioids and benzodiazepines).
• Dexmedetomidine provides sedation and anxiolysis, while producing little effect on level of arousal and cognitive function.  In essence, it reduces discomfort while permitting the patient to arouse for a neurologic examination.
   

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FILE RESEND. This was tested via email and will hopefully work. I apologize for errors - Dlemkin (webmaster)

What is the diagnosis? (DON'T LOOK DOWN AT THE ANSWER)

50 year-old male prisoner s/p assault, + LOC

CT shows right-sided traumatic subarachnoid hemorrhage

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Therapeutic hypothermia is generally accepted as a useful intervention that should be employed in patients that are resuscitated after cardiac arrest. Many protocols for cooling are relatively complicated, involving endovascular catheters, cooling blankets, cooling helmets, or other devices that are expensive and not widely available. The cooling process can actually be fairly simple, however, with ice and cool IV fluids. The most recent study that demonstrated this used nothing more than application of ice to the groin, neck, and axillae; and administration of 4^o C IVF infused at 30cc/kg at 100ml/min via two peripheral catheters. Sedation or paralysis + intubation was used as per the norm.

Patients receiving this simple intervention were able to achieve goal temperature of 32^o-34^o C within 3-4 hours, and hypothermia was maintained for a full 24 hours before rewarming.

The study shows that expensive equipment and complicated protocols are not necessary for therapeutic hypothermia.

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                Involves an avulsion of the flexor digitorum profundus  (FDP) tendon from its insertion on the distal phalanx.

     Ring finger is most commonly involved.

                Usually occurs from a grabbing attempt (resulting in forced DIP extension during maximal FDP contraction) as would occur while attempting to grab someone’s jersey such as in football or rugby.

Clinically, there is normal passive DIP ROM with loss of active flexion. Examine this by asking the patient to flex the fingertip at the DIP while the PIP joint is held in extension.

*Remember that patients with a 90% full-thickness tendon laceration may still have normal (albeit painful) range of motion. The examiner must evaluation the strength of the tendon against resistance. This injury is commonly missed as it is diagnosed as a “jammed” finger.

Plain films may show a bony avulsion, but are often negative.

Treatment is primary repair especially with large bony fragments. Partial ruptures can be treated nonoperatively at the discretion of the hand surgeon.

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