UMEM Educational Pearls

Category: Critical Care

Title:

Keywords: Botulism, IVDA (PubMed Search)

Posted: 7/2/2019 by Robert Brown, MD (Emailed: 2/28/2021)
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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: Critical Care

Title: Utilization of the Mechanical Ventilator in Cardiac Arrest

Keywords: CPR, Cardiac Arrest (PubMed Search)

Posted: 11/15/2016 by Rory Spiegel, MD (Emailed: 2/28/2021)
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It is well documented that when left to our own respiratory devices we will consistently over-ventilate patients presenting in cardiac arrest (1). A simple and effective method of preventing these overzealous tendencies is the utilization of a ventilator in place of a BVM. The ventilator is not typically used during cardiac arrest resuscitation because the high peak-pressures generated when chest compressions are being performed cause the ventilator to terminate the breath prior to the delivery of the intended tidal volume. This can easily be overcome by turning the peak-pressure alarm to its maximum setting. A number of studies have demonstrated the feasibility of this technique, most recently a cohort in published in Resuscitation by Chalkias et al (2). The 2010 European Resuscitation Council guidelines recommend a volume control mode at 6-7 mL/kg and 10 breaths/minute (3).

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Category: Critical Care

Title:

Keywords: amikacin, Torsades de pointes, QT prolongation (PubMed Search)

Posted: 8/20/2019 by Quincy Tran, MD (Emailed: 2/28/2021)
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Torsades de pointes and QT prolongation Associated with Antibiotics

 

Methods

The authors queried the United States FDA Adverse Event Reporting System (FAERS) from 01/01/2015 to 12/31/2017 for reports of Torsade de points/QT prolongation (TdP/QT).

Reporting Odd Ratio (ROR) was calculated as the ratio of the odds of reporting TdP/QTP versus all other ADRs for a given drug, compared with these reporting odds for all other drugs present in FAERS

Results

FAERS contained 2,042,801 reports from January 1, 2015 to December 31, 2017. There were 3,960 TdP/QTP reports from the study period (0.19%).

 

Macrolides               ROR 14 (95% CI 11.8-17.38)

Linezolid                  ROR 12 (95% CI 8.5-18)

Amikacin                 ROR 11.8 (5.57-24.97)

Imipenem-cilastatin ROR 6.6 (3.13-13.9)

Fluoroquinolones   ROR 5.68 (95% CI 4.78-6.76)

 

Limitations:

These adverse events are voluntary reports

There might be other confounded by concomitant drugs such as ondansetron, azole anti-fungals, antipsychotics.

 

Bottom Line:

This study confimed the previously-known antibiotics to be associated with Torsades de pointes and QT prolongation (Macrolides, Linezolid, Imipenem and Fluoroquinolones). However, this study  found new association between amikacin and Torsades de pointes/QT prolongation.

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Category: Critical Care

Title:

Keywords: Right Ventricle, RV Size (PubMed Search)

Posted: 11/5/2019 by Kim Boswell, MD (Emailed: 2/28/2021)
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Rapid Assessment of the RV on Bedside Echo

There are several causes of acute RV dysfunction resulting in a patient presenting to the ER with unstable hemodynamics. Some of these include acute cor pulmonale, acute right sided myocardial infarction and acute submassive or massive pulmonary embolism. While bedside assessment of the LV function is often performed by the ED physician, simultaneous evaluation of the RV can provide crucial information that can help guide therapeutic decisions to prevent worsening of the patient’s clinical condition. A rough guideline to determine RV size and function is below using the apical 4 chamber view.

Normal RV size :            <2/3 the size of the LV

Mildly enlarged RV :       >2/3 the size of the LV, but not equal in size

Moderately enlarged RV:  RV size = LV size

Severely enlarged RV:      RV size > LV size

Patients who are found to have RV dilation should be given fluids in a judicious fashion as the RV is not tolerant of fluid overload. Early diagnosis of the cause of acute RV failure should be sought to guide definitive therapy, but early institution of inotropic support should be considered. Frequent reassessments of biventricular function during resuscitation should be performed.

 

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Attachments

Presentation2.pptx (178 Kb)


Category: Toxicology

Title: Hydrofluoric Acid Burns

Keywords: hydrofluoric acid, burn, chemical burn, HFA, calcium gluconate (PubMed Search)

Posted: 9/5/2010 by Dan Lemkin, MD, MS (Emailed: 2/28/2021) (Updated: 10/2/2010)
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Hydrofluoric acid is a weak acid used primarily in industrial applications for glass etching and metal cleaning/plating. It is contained in home rust removers. Although technically a weak acid, it is very dangerous and burns can be subtle in appearance while having severe consequences.

Hydrofluoric acid burn

Wilkes G. Hydrofluoric Acid Burns. Jan 28, 2010. 
http://emedicine.medscape.com/article/773304-overview

  • 2 mechanisms that cause tissue damage*
    • corrosive burn from the free hydrogen ions
    • chemical burn from tissue penetration of the fluoride ions
  • Clinical features*
    • Cutaneous burns - absent findings to white-blue appearance
    • Pulmonary edema
    • Hypocalcemia, hyperkalemia, hypomagnesemia
  • Treatment*
    • Decontaminate by irrigation with copious amounts of water.
    • With any evidence of hypocalcemia, immediately administer 10% calcium gluconate IV.
    • Cutaneous burns:
      • Apply 2.5% calcium gluconate gel to the affected area. If the proprietary gel is not available, constitute by dissolving 10% calcium gluconate solution in 3 times the volume of a water-soluble lubricant (eg, KY gel). For burns to the fingers, retain gel in a latex glove.
      • If pain persists for more than 30 minutes after application of calcium gluconate gel, further treatment is required. Subcutaneous infiltration of calcium gluconate is recommended at a dose of 0.5 mL of a 5% solution per square centimeter of surface burn extending 0.5 cm beyond the margin of involved tissue (10% calcium gluconate solution can be irritating to the tissue).
        • Do not use the chloride salt because it is an irritant and may cause tissue damage.

*Extracted from emedicine article.

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Question

50 year-old male with cough and dyspnea. What's the diagnosis?

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While chest X ray (CXR) is routinely obtained in the setting of traumatic injury, ultrasound (US) is a fast and reliable way to evaluate for life-threatening traumatic injuries requiring emergent intervention, and is supported by the Eastern Association for the Surgery of Trauma (EAST) guidelines. A recent Cochrane Review compared the test characteristics of chest US vs CXR for detection of traumatic pneumothorax when using Chest CT or thoracostomy as the gold standard.

  • Primary end point: sensitivity and specificity for pneumothorax
  • US performed by nonradiologists.
  • 9 studies, 1271 patients, 410 of which had a pneumothorax
  • Summary sensitivity: US 0.91 (95% CI 0.85-0.94), ranging from  0.82-0.98 in the included studies, vs. CXR 0.47 (95% CI 0.31- 0.63) ranging from 0.09 to 0.75
  • Summary specificity: US 0.99 (95% CI 0.97-1.00, ranging from  0.96-1.00 vs. CXR 1.00 (95% CI 0.97- 1.00), ranging from 0.98 to 1.00

There possible weaknesses of this study, including blinding in the original studies, and several studies may or may not have been at risk for bias as their risk of bias was ‘unclear’.  However, the results were consistent across the studies analyzed and remained similar after sensitivity analysis.

Several anatomical as well as patient care issues may confound US findings for pneumothorax such as the presence of bleb, prior thoracic surgery or pathology, as well as main stem intubation.

Bottom line:  While the presence of pneumothorax is on either CXR or US is highly likely to represent the a true pneumothorax, ultrasound is a far superior screen for the detection of pneumothorax in the trauma patient.

 

 

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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: 2/28/2021)
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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: Orthopedics

Title: Fulcrum test

Posted: 10/1/2017 by Brian Corwell, MD (Emailed: 2/28/2021) (Updated: 2/28/2021)
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https://www.physio-pedia.com/Fulcrum_Test


Category: Orthopedics

Title: Morel-Lavall e lesion

Posted: 10/1/2017 by Brian Corwell, MD (Emailed: 2/28/2021) (Updated: 2/28/2021)
Click here to contact Brian Corwell, MD

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4126145/