UMEM Educational Pearls

Category: Toxicology

Title: Valproic acid toxicity

Keywords: Valproic acid (PubMed Search)

Posted: 10/16/2014 by Hong Kim, MD, MPH (Emailed: 8/20/2019)
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Valproic acid (VPA) is often used to treat seizure disorder and mania as a mood stabilizer. The mechanism of action involves enhancing GABA effect by preventing its degradation and slows the recovery from inactivation of neuronal Na+ channels (blockade effect).

VPA normally undergoes beta-oxidation (same as fatty acid metabolism) in the liver mitochondria, where VPA is transported into the mitochondria by carnitine shuttle pathway.

In setting of an overdose, carnitine is depleted and VPA undergoes omega-oxidation in the cytosol, resulting in a toxic metabolite.

Elevation NH3 occurs as the toxic metabolite inhibits the carbomyl phosphate synthase I, preventing the incorporation of NH3 into the urea cycle.

Signs and symptoms of acute toxicity include:

  • GI: nausea/vomiting, hepatitis
  • CNS: sedation, respiratory depression, ataxia, seizure and coma/encephalopathy (with serum concentration VPA: > 500 mg/mL)

Laboratory abnormalities

  • Serum VPA level: signs of symptoms of toxicity does not correlate well with serum level.
  • NH3: elevated
  • Liver function test: elevated AST/ALT
  • Basic metabolic panel: hypernatremia, metabolic acidosis
  • Complete blood count: pancytopenia

Treatment: L-carnitine

  • Indication: hyperammonemia or hepatotoxicity
  • Symptomatic patients: 100 mg/kg (max 6 gm) IV (over 30 min) followed by 15 mg/kg IV Q 4 hours until normalization of NH3 or improving LFT
  • Asymptomatic patients: 100 mg/kg/day (max 3 mg) divided Q 6 hours.

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Category: Critical Care

Title:

Keywords: Alarm Fatigue (PubMed Search)

Posted: 5/20/2019 by Robert Brown, MD (Emailed: 8/20/2019) (Updated: 8/20/2019)
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Takeaways

In a study of alarms from 77 monitored ICU beds over the course of a month at the University of California, San Francisco, false alarms were common. Accellerated Ventircular Rhythms (AVRs) made up roughly one third of the alarms, and of the more than 4,361 AVRs, 94.9% were false while the remaining 5.1% did not result in a clinical action.

While this study had a majority of patients in the Med/Surg ICUs, a minority were from the cardiac and neurologic ICUs giving it some broad applicability. This study adds to the literature indicating there are subsets of alarms which may not be necessary or which may require adjustment to increase specificity.

Suba S, Sandoval CS, Zegre-Hemsey J, et al. Contribution of Electrocardiographic Accelerated Ventricular Rhythm Alarms to Alarm Fatigue. American Journal of Critical Care. 2019; 28(3):222-229

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Category: Critical Care

Title:

Keywords: Botulism, IVDA (PubMed Search)

Posted: 7/2/2019 by Robert Brown, MD (Emailed: 8/20/2019)
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Takeaways

Don’t miss the injecting drug users with botulism!

Wound botulism presents as descending paralysis when Clostridium botulinum spores germinate in anaerobic necrotic tissue. There have been hundreds of cases in the last decade, but it is poorly reported outside of California.

Black tar heroin and subcutaneous injection (“skin popping”) carry the highest risk, but other injected drugs and other types of drug use suffice. C botulinum spores are viable unless cooked at or above 85°C for 5 minutes or longer and this is not achieved when cooking drugs. 

Early administration of botulism anti-toxin (BAT) not only saves lives but can prevent paralysis and mechanical ventilation. An outbreak of 9 cases between September 2017 and April 2018 cost roughly $2.3 million, in part because patients didn’t present on average until 48 hours after symptom onset and it took an additional 2-4 days before the true cause of their respiratory depression and lethargy were understood. One patient died.

PEARL: talk to your injecting drug users about the symptoms of botulism: muscle weakness, difficulty swallowing, blurred vision, drooping eyelids, slurred speech, loss of facial expression, descending paralysis, and difficulty breathing. Consider botulism early in your patients who inject drugs but who do not respond to naloxone or who exhibit prolonged symptoms. Testing at the health department is performed with mouse antibodies to Botulism Neurotoxin (BoNT) combined with the patient’s serum.

 

 

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Category: International EM

Title: Fever and Polyarthralgia

Keywords: International, Chikungunya, vector-borne, (PubMed Search)

Posted: 3/5/2014 by Andrea Tenner, MD (Emailed: 8/20/2019)
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Case Presentation:

53 yo male presents with fever, myalgia, maculopapular rash, and severe polyarthralgia. He just returned from a cruise to the Caribbean islands.

Clinical Question:

What is the diagnosis?

Answer:

Chikungunya Virus

  • Travelers who go to the Caribbean are at risk of getting chikungunya. Cases have been reported in Saint Martin, Martinique, and Guadeloupe. In addition, travelers to Africa, Asia, and islands in the Indian Ocean and Western Pacific are also at risk.
  • Mosquito vector, incubation 3-7 days
  • Joints involved are typically hands and feet, usually symmetric, severe arthralgia often debilitating
  • Dx: serology - ELISA, IgM
  • Treatment: IVF, NSAIDS, supportive

Bottom Line:

  • Include Chikungunya in your differential of non-specific fever, rash, headache and arthralgia in travelers the Caribbean and endemic areas.

University of Maryland Section of Global Emergency Health

Author: Veronica Pei, MD

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Category: Visual Diagnosis

Title: What's the Diagnosis? Case by Dr. Ali Farzad

Posted: 4/7/2014 by Haney Mallemat, MD (Emailed: 8/20/2019) (Updated: 8/20/2019)
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Question

23 year-old female presents complaining of progressive right lower quadrant pain after doing "vigorous" pushups. CT abdomen/pelvis below. What’s the diagnosis? (Hint: it’s not appendicitis)

 

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Category: Critical Care

Title: Lung Protective Ventilation in the Emergency Deparment

Keywords: lung protective ventilation, ARDS (PubMed Search)

Posted: 3/21/2017 by Rory Spiegel, MD (Emailed: 8/20/2019)
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While lung protective ventilatory strategies have long been accepted as vital to the management of patients undergoing mechanical ventilation, the translation of such practices to the Emergency Department is still limited and inconsistent.

Fuller et al employed a protocol ensuring lung-protective tidal volumes, appropriate setting of positive end-expiratory pressure, rapid weaning of FiO2, and elevating the head-of-bed. The authors found that the number of patients who had lung protective strategies employed in the Emergency Department increased from 46.0% to 76.7%. This increase in protective strategies was associated with a 7.1% decrease in the rate of pulmonary complications (ARDS and VACs), 14.5% vs 7.4%, and a 14.3% decrease in in-hospital mortality, 34.1% vs 19.6%.

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Category: Visual Diagnosis

Title: Visual Dx (Courtesy of Maite Huis in 't Veld)

Posted: 10/5/2018 by Michael Bond, MD (Emailed: 8/20/2019) (Updated: 8/20/2019)
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Question

33 y/o M with PMH of ETOH induced pancreatitis presents with epigastic/RUQ pain & N/V after drinking last night, per patient his usual “pancreas pain”. The nurse shows you his blood tubes because they look “milky”. Lipase 1200, Ca 6.8.

 



What lab test would you add?

 

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Category: Pediatrics

Title: Tinea Capitis

Posted: 3/9/2013 by Rose Chasm, MD (Emailed: 8/20/2019) (Updated: 8/20/2019)
Click here to contact Rose Chasm, MD

  • Tinea capitis (ringworm of the scalp) is caused by dermatophytic fungi
  • Trichophyton tonsurans is the most common species in the US, and does NOT flouresce under Wood's lamp
  • Griseofulvin (20-25mg/kg/ day orally) is the standard first-line therapy in children older than 2 years, and has a good safety profile
  • Both tablet and suspension formulations are available, and it should be taken with food that are high in fat to increase drug concentrations
  • NO laboratory assessment of hepatic enzymes is required during the 8-week therapy course in children who have no history or clinical examination findings concerning for liver disease.
  • Topical antifungal agents are ineffective because they do not penetrate sufficiently into the hair shaft.

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Category: Pediatrics

Title: Visual Diagnosis Pediatrics: Case thanks to Ari Kestler MD (@KestlerMD) and Haney Mallemat MD (@CriticalCareNow)

Keywords: non-accidental trauma, clavicle fracture, neonate, pediatrics, abuse (PubMed Search)

Posted: 10/4/2014 by Ashley Strobel, MD (Emailed: 8/20/2019)
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Question

Q: What is wrong with this baby? And what Dx should you entertain?

Previously healthy 7d old presents after difficulty feeding, one episode of vomiting and now with intermittent apneic episodes.

 

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Attachments

Clavicle_Fracture.jpg (1,743 Kb)


Category: Toxicology

Title: Octreotide for Pediatric Sulfonylurea Poisoning

Keywords: octreotide, sulfonylurea (PubMed Search)

Posted: 4/12/2013 by Bryan Hayes, PharmD (Emailed: 8/20/2019) (Updated: 4/13/2013)
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Methods: A large retrospective case series evaluated 121 children under 6 years old with hypoglycemia from a sulfonylurea ingestion.

Results:

  • In addition to dextrose, patients who received octreotide had a median of zero hypoglycemic episodes after octreotide (compared to 2 before treatment, p < 0.0001).
  • Median blood glucose concentrations after receiving octreotide were also higher (62 mg/dL vs 44, p < 0.001).
  • Most required only 1 dose of octreotide with no reported adverse effects.


Authors' Conclusion: Octreotide administration decreases the number of hypoglycemic events and increases blood glucose concentrations in children with sulfonylurea ingestion.

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Category: Infectious Disease

Title: Avian Influenza H7N9

Posted: 4/12/2013 by Andrea Tenner, MD (Emailed: 8/20/2019) (Updated: 8/20/2019)
Click here to contact Andrea Tenner, MD

General Information:

-As of April 5th, 14 confirmed cases of a new influenza A virus (H7N9) have occurred in China.  Six of those have died. 

-Presumed transmission via infected poultry in bird markets, and thus far no person-to-person transmission has occurred.

-Likely susceptible to oseltamavir or inhaled zanamivir

 

Area of the world affected:

-China

Relevance to the US physician:

- Suspect in patients with a respiratory illness and appropriate travel history.

- Refer to CDC within 24 hours if test positive for flu A but cannot be subtyped

- If H7N9 is suspected, patients should be under droplet and airborne precautions

 

Bottom Line:

No human-to-human transmission from H7N9 thus far, but the possibility exists.  Any unsubtypeable influenza A patient should be placed on droplet and airborne precautions and oseltamavir or zanamivir started immediately.

 

University of Maryland Section of Global Emergency Health
Author: Andi Tenner, MD, MPH

 

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Category: Critical Care

Title: Adrenal Insufficiency

Posted: 4/12/2013 by Haney Mallemat, MD (Emailed: 8/20/2019) (Updated: 8/20/2019)
Click here to contact Haney Mallemat, MD

Adrenal insufficiency (AI) can be a life-threating condition and is classified as primary (failure of the adrenal gland) or secondary (failure of hypothalamic- pituitary axis).

Common causes of primary adrenal insufficiency include autoimmune destruction, infectious causes (TB and CMV), or interactions with drugs (e.g., anti-fungals, Etomidate, etc.). Secondary causes are usually due to abrupt withdrawal of steroids after chronic use, although sepsis and diseases of the hypothalamus or pituitary (e.g., CVA) may occur.

Signs and symptoms include fatigue, weakness, skin pigmentation, dizziness, abdominal pain, and orthostatic hypotension; it should be suspected with any of the following: hyponatremia, hyperkalemia, hypoglycemia, hypercalcemia, low free-cortisol level, and hemodynamic instability despite resuscitation.

Treatment:
• Correct underlying the disorder
• Resuscitation and hemodynamic support
• Correct hypoglycemia and electrolyte abnormalities
• Treat with hydrocortisone, cortisone, prednisone, or dexamethasone +/- fludrocortisone (Note: dexamethasone is attractive choice in the ED because it will not interfere with ACTH stimulation test)


 

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