UMEM Educational Pearls

In the ICU, diabetes insipidus (DI) develops in patients with pituitary surgery, brain trauma, intracranial hypertension and brain death.  Criteria include the following:

• urine output >200 ml/hr or 3 ml/kg/hr
• urine osmolality <150 mOsm/kg
• serum sodium>145 mEq/L
• urine specific gravity<1.005

In the ICU, patients are typically unable to consume free water to compensate for urinary losses, and dehydration, hypotension and hypernatremia occur.  Clinical signs may not appear until sodium levels surpass 155-160 mEq/L or serum osmolality surpsses 330 mOsm/kg. 

Symptoms include confusion, lethargy, coma, seizures and cerebral shrinkage associated with subdural or intraparenchymal hemorrhage. 

Treatment includes

• controlling polyuria with vasopressin (antidiuretic, vasoconstrictive effects) and desmopressin (DDAVP - antidiuretic effect)
• calculate and replace free water loss
• TBW deficit (L) = body weight (kg) x 0.6 x (Na-140)/Na
• monitor and replace urine losses hourly (using gastric access if possible)
• monitor serum sodium and adjust therapy every 4 hours closely monitor for hyperglycemia and treat to prevent osmotic diuresis due to glucosuria

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Slight revisions have been made in what is considered to be normal QRS duration.
In children < 4yo, a normal QRS duration is < 90ms.
In children 4-16yo, a normal QRS duration is < 100ms.
Above the age of 16, a normal QRS duration is < 110m.

Consider these numbers when evaluating patients for aberrant conduction (e.g. toxicologic reasons as well) and when defining conduction blocks.

Reference:
Surawicz B, Childers R, Deal BJ, et al. AHA/ACCF/HRS Recommendations for the standardized interpretation of the electrocardiogram, Part III: Intraventricular conduction disturbances. A scientific statement from the American Heart Association Electrocardiography and Arrhythmias Committee, Council on Clinical Cardiology; the American College of Cardiology Foundation; and the Heart Rhythm Society. J Am Coll Cardiol 2009;53(11):976-981.

• seizure disorder occuring in infants and children <1 year of age
• mostly occur between ages 4-8 months
• classic spasm is sudden, simultaneous flexion of the head and trunk with felxion and adduction of the extremities (salaam attack Blitz-krampf)
• occurs in clusters of diminishing severity
• initiated or aggrevated by transition from sleep to wakefulness or emotions
• EEG demonstrates hypsarrhythmia: high-voltage, irregular, slow waves occuring out of synch with multiple foci
• most resolve over time without therapy, but most children have some level of mental retardation or other seizure disorder

• The terms pseudotumor cerebri, benign intracranial hypertension, and idiopathic intracranial hypertension (IIH), are all synonymous terms which describe a condition of elevated intracranial pressure (ICP), but the latter is the preferred term of use.
• IIH almost ubiquitously presents with a generalized headache and papilledema (i.e. fundoscopic examination imperative!).  Visual disturbance and non-specific symptoms such as dizziness may also be present.
• Elevated ICP and papilledema are clinical emergencies until the presence or absence of an intracranial mass is confirmed. 
• The following conditions must be met in order to diagnose IIH:

1. Non-focal neurologic examination (except for 6th nerve palsy in some cases)
2. Elevated opening pressure on lumbar puncture, > 20 to 25 mmH2O (perform only after risk for herniation assessed!)
3. Normal cytologic and chemical cerebrospinal fluid analysis
4. Small, symmetric brain ventricles on neuroimaging
5. Exclusion of other sources of IH such as venous sinus thromboses by obtaining an MRI/venographic study of the head

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PRBC Transfusion Threshold for Patients with Cardiac Disease

• As previously discussed, the PRBC transfusion threshold for the general population of critically ill patients is a Hgb < 7 gm/dL.
• Traditional teaching has been to maintain a Hgb > 10 gm/dL in patients with a history of CAD.
• This threshold stems from a 1950s cohort of Jehovah's Witness patients, and several observational studies, that demonstrated increased perioperative mortality in patients whose Hgb was < 10 gm/dL.
• Recent studies, however, have found that patients with a history of CAD tolerate lower Hgb levels without increases in morbidity or mortality.  In fact, current cardiovascular surgery guidelines favor a conservative Hgb threshold (7 gm/dL) for patients with CAD.
• Importantly, the Hgb threshold of < 7 gm/dL for PRBC transfusion applies to patients with simply a history of CAD and not to patients with evidence of an acute coronary syndrome (STEMI, NSTEMI, unstable angina).  Guidelines continue to recommend a Hgb > 10 gm/dL for patients with ACS.

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A review of the PERC rule...

The "PERC Rule"  is used to assess a patient's risk for probability of PE in the emergency department. It involves evaluating the presence or absence of 8 clinical criteria to arrive at a pretest probability.  And remember, this rule is supposed to be used for patients with really low pretest probability where you weren't concerned about PE to begin with. Some experts claim that "PERC negative" on the chart proves you considered PE in the differential diagnosis. But the test isn't designed to be used on EVERY patient as a means to rule out PE. Only use if you thought about the disease in a low risk patient and didn't plan on getting a d-dimer or further testing. 

The criteria are (all must be YES):

age < 50 years

heart rate less than 100 beats per minute

room air oxygen saturations 95% or greater

no prior deep venous thrombosis [DVT] or PE

no recent trauma or surgery (4 weeks)

no hemoptysis

no exogenous estrogen

no clinical signs suggestive of DVT (Unilateral leg swelling on visual inspection

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Three common herbal supplements are reported to be associated with clinically significant hypokalemia: aloe vera, gossypol (used as a male contraceptive), and licorice.

Another popular herbal supplement is reported to be associated with clinically significant hyperkalemia: oleander.

Always ask your cardiac patients (especially those on digoxin) if they are taking any of these herbal supplements!


[Tachjian A, Maria V, Jahangir A. Use of herbal products and potential interactions in patients with cardiovascular diseases. J Am Coll Cardiol 2010;55:515-525.]

Carpal Tunnel Syndrome (CTS):

• A compressive neuropathy of the median nerve at the wrist as it travels through the carpal tunnel. 
• Median nerve is bound on three sides by carpal bones and anteriorly by the transverse carpal ligament.  Surgical repair typically consists of cutting this ligament to allow decompression of the nerve.
• The neuropathy results in:
  • parasethesia of the thumb, index and middle fingers
  • weaknesss of the thumb and thenar muscles.
• NO physical exam test has great senstivity or specificity for CTS. The two most common are:
  • Phalen's test: hyperflexion of the wrist. Need to hold for 60 seconds.  Sensitivity ~68% and Specificity ~73%
  • Tinel Sign: tapping over cubital tunnel to produce parasthesia along the median nerve. Sensitivity ~50% and Specificity ~77%.
• Increased risk in those patients with:
  • Diabetes
  • Rheumatoid arthritis
  • hypothyroidism
  • amyloidosis

• also known as acute cerebellitis of childhood
• most commonly affects children 2-6 years old
• about 50%  have a history of recent URI or viral GI illness
• abrupt onset of ataxia which may be mild to severe, and findings usually include hypotonia, tremor, horizontal nystagmus, and dysarthria
• child often is irritable with nausa/vomiting
• sensory exam and DTR's are normal
• CT and MRI are normal
• CSF usually demonstrates an increase in WBC, with a predemonance of lymphocytes
• 90% recover without any specific therapy in 6-8 weeks (steroids are not indicated).

• The Brachial Plexus is a bundle of nerve roots arising from C5, C6, C7, C8, and T1.
• Brachial plexus injuries (BPI) result from severe traction forces on the limb.
• The most common sources of BPI are motorcycle accidents and birth palsy (i.e. Erb or Duchenne Palsy) affecting the upper part of the plexus (C5, C6) and causing shoulder and biceps muscle weakness.
• Injury to C7 >>> wrist weakness.
• Injury to C8 and T1 >>>  forearm and intrinsic hand muscle weakness.
• Injury to stellate ganglion or cervical sympathetic trunk >>> Horner's Syndrome.
• MRI of the upper extremity is the standard imaging modality used to make the diagnosis.

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It is true, 1/3 of Americans are obese.  There is conflicting evidence regarding the mortality risk of obesity (defined as BMI>30 kg/m²) in critically ill patients. 

It has been shown that abdominal fat has greater consequences than peripheral obesity, and based on this, a recent study has utilized the sagittal abdominal diameter (SAD) in ICU patients to show that abdominal obesity (as differentiated from BMI) poses an independent risk of death.  The SAD detects visceral fat, which has been shown to have metabolic and immune health consequences, including the following:

-incidence and severity of certain infections is higher

-excess adipocytes are associated with elevated levels of proinflammatory factors that favor insulin resistance, diabetes, dyslipidemia and hypertension, all of which lead to microcirculatory dysfunction

-rates of required renal replacement therapy and abdominal compartment syndrome correlate to increased SAD

-there is also a trend toward a longer length of ventilator weaning

See you at the gym.

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Secondary Hypertension...say what?

We obviously see tons of patients in the ED with hypertension, and we are very comfortable with both symptomatic and asymptomatic presentations. Most of these patients have essential or primary hypertension. Some patients, however, may have secondary hypertension (i.e. something is causing it). Although we will refer patients to a primary care physician for further management and workup it is worth discussing when to suspect other diagnoses as the cause of the hypertension. Is it out job necessarily to diagnose these conditions in the ED? No. 

Causes of secondary hypertension to consider:

• Obstructive sleep apnea
• Renal disease
• Renal artery stenosis (think older person with HTN and abdominal bruit)
• Coarctation (young person with HTN-ever wonder why pediatricians palpate upper and lower extremity pulses in the office?)
• Cushing's disease (excess cortisol-patient may have new diabetes, have abdominal striae, and easy bruising)
• Hyperaldosteronism (due to an adrenal tumor)...think about if a patient comes to the ED and is repeatedly hypokalemic and hypertensive
• Pheochromocytoma (episodes of flushing, hypertension, palpitations, etc.)
• Hypothyroidism (not myxedema coma or storm)...commonly causes elevated diastolic BP. 
• Hyperthyroidism 

Consider the ABCDE mnemonic:

A-Accuracy (is it really htn?), Apnea, Aldosteronism

B-Bruits, Bad Kidneys

C-Catecholamines, Coarctation, Cushing's 

D-Drugs, Diet

E-Endocrine

Aren't you glad you didn't do a Medicine residency???

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Patients with pericarditis are generally treated with high-dose aspirin (e.g. 2-4 gms/day) or other NSAIDs in high dose. However, when myocarditis is also present (e.g. elevated TN levels), lower dosages of aspirin (e.g. 500 mg TID) or other NSAIDS should be used. The higher dosages of anti-inflammatory medications in the setting of myocarditis are thought to exacerbate the myocarditic process and increase mortality (animal studies).

Imazio M, Spodick DH, Brucato A, et al. Controversial Issues in the management of pericardial diseases. Circulation 2010;121:916-928.

All to often we see children that are sent to the ED for "Pink Eye" as the school nurse will not allow them back into class unless they are treated with antibiotics.  A recent study out of New York identified 4 factors that are associated with low risk (<8% chance) of bacterial (culture postive) conjunctivitis.  They are:

1. age 6 years
2. presentation during April through November
3. watery or no discharge
4. no glued eye in the morning

An editorial in journal watch comments that if this study can be replicated in other geographic areas we could change the practice of prescribing antibiotics that are not necessary.

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EMTALA stipulates that any patient presenting to the Emergency Department is required to receive a medical screening exam regardless of age, ability to pay, or whether or not a parent accompanies the child.

EMTALA supersedes any state/local provisions or laws.

In performing a medical screening exam if an emergency medical condition exists then diagnostic testing, surgery or even transfer of hospitals may be appropriate without ever obtaining parental consent

MInors have the right to give or refuse informed assent of a procedure

If their is conflict between physician, parent or patient in the rendering of emergent care the physician must weigh the severity of the condition, risks and benefits of the treatment, as well as the patients maturity and cognition.  The physician may have to seek ethical committee review, or assistance from either social services or the court system.

If an emergent condition does not exist, EMTALA does not apply after the MSE.

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• Cerebral edema develops in 20-90% of children with DKA, and mortality ranges from 20-90%
• Children younger than 5, and with newly diagnosed diabetes are at higher risk, and the risk in children in general is MUCH higher than the risk in adults
• Cerebral edema usually results from osmolarity changes during treatment, but may precede treatment
• Limit fluid repletion to isotonic fluids (Normal Saline), at a rate of no faster than 10-20 mL/kg/hr (In shock, resuscitate as usual)
• Head CT Is of limited value as the majority of children in DKA may show signs of subclinical cerebral edema, TREAT BASED ON CLINICAL SIGNS, and do not delay treatment for head CT which is likely to be abnormal in ALL kids
• Bicarb is implicated in increasing the risk of cerebral edema - focus on correction of acidosis with insulin and appropriate fluids, NOT bicarb

...more to come.

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Several drugs and compounds may be radiopaque on an abdominal radiograph. This may be helpful in an overdose to determine ingestion or amount ingested. Attached is a pic a patient that ingested potassium sustained release tables.

The mneumonic CHIPES will help you remember which are:

C - Calcium Carbonate, chloral hydrate

H - Heavy metal - like Mercury, lead

I - Iron and Iodine

P - Phenothiazines (compound that has S(C₆H₄)₂NH in it), drugs that include: antipsychotics like chlorpromazine (thorazine) and antiemetics like prochlorperazine (compazine)

E - Enteric coated pills

S - Solvents [halogenated ones like chloroform] and Sustained Release preparations [Lithobid and K-Dur]

Attachments

• 1004150936_KCl_patient_1.JPG (182 Kb)

• Bitemporal hemianopsia ("tunnel vision") is a type partial blindness affecting the lateral halves of vision in both eyes (see attached diagram), and is usually associated with lesions or compression of the optic chiasm.
• Always assess visual fields in patients presenting with neurologic complaints, particularly when associated with visual abnormality, headache, focal deficit, and endocrine-related symptoms.
• One of the simplest ways of assessing visual fields is to (1) stand directly in front of the patient, (2) instruct them to stare straight at your nose, (3) laterally extend both your arms to 2/3 of full capacity (i.e. elbows slightly bent), and (4) ask them where they see your wiggling fingers (i.e. left or right).  
• Bitemporal hemianopsia commonly results from pituitary microadenomas (< 1 cm) and macroadenomas (> 1 cm), which are sometimes associated with acromegaly and Cushing's Disease.

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Attachments

• 1004140823_Visual_Field_Abnormalities.jpg (44 Kb)

Type B Lactic Acidosis

• In the critically ill, patients may often have elevated lactate levels without ongoing tissue hypoperfusion.
• In these patients it is important to consider the causes of what is referred to as "Type B Lactic Acidosis".
• Pertinent to critically ill ED patients, consider the following:
  • Type B1 - related to underlying disease
    • renal faiilure
    • hepatic failure
    • malignancy
    • HIV
  • Type B2 - effects of drugs/toxins
    • acetaminophen
    • alcohols
    • beta-adrenergic agents: epinephrine
    • cocaine, methamphetamine
    • propofol
    • salicylates
    • valproic acid
    • metformin
  • Type B3 - inborn errors of metabolism

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