UMEM Educational Pearls

Syndesmotic sprain aka a “high ankle sprain”

Ankle injuries make up almost 30% of the injuries in professional football

High ankle injuries make up between 16 and 25% of these injuries in the NFL (lateral most common)

               10% in general population

In comparison to lateral ankle sprains, high ankle sprains result in significantly more missed games, missed practices and required a longer duration of treatment

Anatomy: The syndesmosis comprises several ligaments and the interosseous membrane

Mechanism: External foot rotation with simultaneous rotation of the tibia and fibula.

               Can lead to a Maisonneuve fracture

Injuries 4x more likely in game setting than practice

A positive proximal squeeze test significantly predicts missed games and practices compared to those without.

 

https://www.youtube.com/watch?v=ThiW_9m7cFM

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Category: Pediatrics

Title: Conjunctivitis-otitis syndrome

Keywords: augmentin, conjunctivitis, AOM, otitis media (PubMed Search)

Posted: 6/8/2018 by Mimi Lu, MD
Click here to contact Mimi Lu, MD

Although conjuncitivitis outside of the neonatal period is commonly caused by viruses, there are times when antibiotics are warranted due to bacterial infections, such as conjuncitivits-otitis syndrome.

  • up to 25% of patients with conjunctivitis have concurrent otitis media (even in the abscence of ear pain) and up to 73% of patients with purulent conjunctivitis
  • Non-typeable H. influenzae is the most common recovered bacteria.
  • For these patients, systemic (oral) antibiotics are recommended and the topical ophthalmic antibiotics are NOT necessary.
  • Antibiotics should cover beta-lactamase producing organisms, e.g. high dose amoxicillin-clavulanic acid (45 mg/kg BID; 600 mg/5mL concentration which is formulated to have less clavulanic acid

Bottom line: Every patient with conjunctivitis should have an examination of his/her TMs, as your management may change.

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Category: Geriatrics

Title: What is a fever, really?

Keywords: fever, infection, physiology (PubMed Search)

Posted: 6/3/2018 by Danya Khoujah, MBBS (Updated: 11/28/2020)
Click here to contact Danya Khoujah, MBBS

Older patients are less likely than their younger counterparts to mount a fever in response to an infection. One explanation is that their basal temperature is lower. Some experts suggest redefining fever in older patients to match this decrease of 0.15C per decade. Therefore, your 80 year old patient would be considered “febrile” if their temperature is above 37.3C, rather than the traditional 38C.

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Category: Pharmacology & Therapeutics

Title: Steroid Induced Leukocytosis

Keywords: steroids, infection, leukocytosis (PubMed Search)

Posted: 6/2/2018 by Ashley Martinelli (Updated: 11/28/2020)
Click here to contact Ashley Martinelli

Steroids induce leukocytosis through the release of cells from bone marrow and the inhibition of neutrophil apoptosis.   This effect typically occurs within the first two weeks of steroid treatment. 

Leukocyte elevation is commonly used in the diagnosis of septic patients; however, this can be hard to discern in patients on concomitant steroid therapy.

A retrospective cohort study of adult patients presenting with fevers and a diagnosis of pneumonia, urinary tract infection, bacteremia, cellulitis, or COPD exacerbation was conducted to determine the maximal level of WBC within the first 24h of admission between patients on acute, chronic, or no steroid treatment.

Results: maximal WBC levels (p< 0.001)

·        Acute steroid therapy: 15.4 ± 8.3 x 10 9/L

·        Chronic steroid therapy: 14.9 ± 7.4 x 10 9/L

·        No steroid therapy: 12.9 ± 6.4 x 10 9/L

An increase in WBC of 5 x 10 9/L can be found in acute and chronic steroid use when presenting with an acute infection and fever.

 

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Category: Orthopedics

Title: Exertional rhabdomyolysis (ER)

Keywords: Heat, exertion, muscle (PubMed Search)

Posted: 5/26/2018 by Brian Corwell, MD
Click here to contact Brian Corwell, MD

Exertional rhabdomyolysis (ER)

The warm weather is here and with it comes an increased risk of ER

Risks include the intensity, duration and types of exercises performed

One of the biggest risks is the exercise experience of the participants, both in those with little to no experience and in those experienced athletes less trained than their counterparts.

Multiple case reports find that intense novel exercises early in the preseason before getting acclimatized and “in shape” carry great risk to the participant. These can be summarized as “too much, too soon, too fast.”

Coaches need to be educated about this and be prepared to detect and effectively handle ER through an emergency action plan.

               -Conditioning workouts need to be phased in rather than start at maximum intensity on day one.

Eccentric exercises appear worse than concentric exercises.

Has been seen in almost all sports, ranging from swimming to golf.

               It’s not just preseason football!

High humidity and high temperature environments increase the likelihood of ER

Males are more vulnerable to ER than females

Increased risk with sickle cell trait and glycogen storage diseases

Multiple drugs may increase individual risk including alcohol, cocaine, amphetamines, MDMA and caffeine.

Implicated medicines include, salicylates, neuroleptics, quinine, corticosteroids, statins, theophylline, cyclic antidepressants and SSRIs

 

 

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Category: Neurology

Title: Lhermitte's Sign

Keywords: myelopathy, myelitis, physical exam (PubMed Search)

Posted: 5/23/2018 by Danya Khoujah, MBBS (Updated: 11/28/2020)
Click here to contact Danya Khoujah, MBBS

Lhermitte’s phenomenon is as a sign of cervical spinal cord demyelination. It is considered positive if flexion of the neck causes a tingling sensation moving down the limbs or trunk, and may be reported as a symptom or elicited as a sign. This is due to stretching of the dorsal column sensory fibers, the commonest cause of which is multiple sclerosis. Other causes include other myelopathies, such as B12 deficiency, radiation and toxic (due to chemotherapy) or idiopathic myelitis. Its sensitivity is low at 16%, but its specificity for myelopathy is high at 97%.

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Category: Critical Care

Title: 2018 Surviving Sepsis Update

Keywords: sepsis, septic shock, guidelines (PubMed Search)

Posted: 5/22/2018 by Kami Windsor, MD
Click here to contact Kami Windsor, MD

  • The Surviving Sepsis Campaign recently republished the 2018 update to their guidelines, namely, the recommendation that physicians initiate treatment measures using a "1-Hour Bundle" rather than the 3 and 6-hour bundles previously recommended:

  • Also included was the level of evidence for each bundle component. There was no additional evidence provided to support the within-one-hour recommendation. 

  • There has been no well-designed, randomized trial to demonstrate benefits to administration of the various bundle components at specific time points. There are observational studies that show benefits to early protocolized therapy, including a restrospective study by Seymour et al. that showed benefits to earlier administration of antibiotics (but notably, not IV fluid administration), primarily in patients with septic shock requiring pressors.2
  • There have been a variety of studies demonstrating harm with unecessary IV fluid administration,3-5 and inappropriate antibiotic use puts patients at risk for C.difficile colitis, drug reactions, and promotes drug-resistant organisms. Studies to date do not examine adverse events in patients initially treated for sepsis who do not end up being septic.

Take Home Points: 

  1. Early recognition of sepsis is crucial to initiating necessary therapies and improving outcomes.
  2. Patients with sepsis and septic shock benefit from early appropriate antibiotics, source control, and appropriate resuscitation.
  3. Empiric treatment of all-comers with possible sepsis with broad spectrum antibiotics and 30ml/kg of IV fluids, in order to meet a 1-hour deadline, has definite potential for harm. 

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Category: Pediatrics

Title: Development of an algorithm for battery ingestion

Keywords: Button batteries, removal (PubMed Search)

Posted: 5/18/2018 by Jenny Guyther, MD (Updated: 11/28/2020)
Click here to contact Jenny Guyther, MD

Takeaways

There were 180 battery ingestions over a 5 year period at two tertiary care children’s hospital.  The median age was 3.8 years (0.7 to 18 years).  The most common symptoms were abdominal pain (17%), and nausea and vomiting (14%).  X-rays detected the location in 94% of patients.

Based on these patients, a treatment algorithm was developed (See attached).  Prospective validation is needed.

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Attachments

battery_algorithm.docx (123 Kb)


Category: Toxicology

Title: Methylene Blue for Poisoning

Keywords: Methylene Blue (PubMed Search)

Posted: 5/17/2018 by Kathy Prybys, DO (Emailed: 5/18/2018) (Updated: 5/18/2018)
Click here to contact Kathy Prybys, DO

Methylene Blue is a dye that was synthesized in the late 1800s as an antimalarial drug. After the emergence of chloroquine its use loss favor partly due to unpopular side effects of temporarily turning the urine, other body fluids, and the sclera blue. Methylene blue is primarily known as a highly effective fast acting antidote for methemboglobinemia. Over the past few years, it has become an important therapeutic modality with expanding uses in cardiac surgery and critical care.  As a potent inhibitor of nitric oxide mediated guanylate cyclase induced endothelium vascular smooth muscle relaxation, it has been shown to be effective in increasing arterial blood pressure and cardiac function in several clinical states, such as septic shock and calcium channel blocker poisoning.

 

BOTTOM LINE:

  • Methylene blue should be considered for treatment of refractory shock from calcium channel and beta blocker poisoning.

  • Clinical improvement in refractory hypotension and reduction of vasopressor dose has been described in several poisoning cases. 

  • Recommended dose is 1–2 mg/kg injection with effects seen within 1 hour.

 

 

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Precedex (dexmedetomidine) is a selective alpha-2 adrenergic receptor agonist used as a sedative.

It is unique among sedatives typically used in the ICU in that it lacks GABA activity and lacks anticholinergic activity.

 

Previous studies have shown significant positive changes in sleep patterns in critically ill patients sedated with dexmedetomidine:

-improved sleep efficiency – decreased sleep fragmentation, decreased stage 1 sleep, increased stage 2 sleep

-improved distribution of sleep (with more than ¾ sleep occurring at night)

 

 

Given importance of sleep and preservation of day-night cycles/ circadian rhythms in prevention of delirium, a recent randomized controlled trial evaluated dexmedetomidine's effect on delirium.

 

100 delirium-free critically ill adults receiving sedatives were randomized to receive nocturnal (21:30-06:15) IV dexmedetomidine (titrated to RASS -1 or max 0.7 mcg/kg/hr) OR placebo until ICU discharge.

 

80% of patients in the dexmedetomidine group remained delirium-free vs 54% in the placebo group.

 

There was no difference in the incidence of hypotension, bradycardia, or both between groups.

 

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Category: Orthopedics

Title: Concussion and dementia

Keywords: Mild traumatic brain injury, concussion (PubMed Search)

Posted: 5/12/2018 by Brian Corwell, MD
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Does mild traumatic brain injury increase risk of dementia?

Background: Most studies of moderate to severe TBI have found an association with increased risk of dementia and earlier onset of Alzheimer’s. There is growing concern that repeated TBIs, even if more mild, can lead to neurodegenerative conditions such as chronic traumatic encephalopathy (CTE). However, the link between mild TBI and dementia risk has not fully been elucidated, especially in the case of mild TBI without loss of consciousness (LOC).

Recent Data: A recent JAMA study evaluated the association between TBI severity, LOC, and dementia diagnosis in 350,000 veterans between 2001-2013. After adjusting for demographics as well as medical and psych comorbidities, veterans with even mild TBI without LOC had more than a 2-fold increase in risk of dementia diagnosis than those with no TBI. The risk increased only slightly if there was LOC (from a hazard ratio of 2.4 to 2.5). Risk was >3-fold for those with moderate-severe TBI.

Take home: TBI of any severity, even without LOC, appears to be associated with long term neurodegenerative consequences. Avoidance of TBI is of the utmost importance, and if TBI occurs, close neurocognitive follow up should occur.  

 

 

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Category: Toxicology

Title: Here comes the adexanet alfa!

Keywords: Factor Xa inhibitor, reversal agent, adexanet alfa, andexxa (PubMed Search)

Posted: 5/4/2018 by Hong Kim, MD, MPH (Emailed: 5/11/2018) (Updated: 5/11/2018)
Click here to contact Hong Kim, MD, MPH

On May 3, the FDA approved adexanet alfa, the reversal agent for factor Xa inhibitors - apixaban and rivaroxaban. It received both U.S. Orphan Drug and FDA Breakthrough Therapy designations. 

Unlike indarucizumab (a monoclonal antibody fragment) to reverse dabigatran (direct thrombin inhibitor) associated bleeding, adexanet alfa is a recombinant modified human factor Xa decoy protein. 

A phase 3 study showed that adexanet alfa decreased the anti-factor Xa activity of rivaroxaban by 92% from baseline and by 94% in apixaban treated participants.

ANNEXA-4 study involving participants with acute major bleeding (GI and intracranial) showed a significant decrease in the anti-factor Xa activity after the bolus dose of adexanet alfa and "effective" hemostasis was noted in 79% of the participants at 12 hours post infusion.

Andexanet alfa is expected to become available in June 2018.

 


Category: Neurology

Title: Predicting ICH Expansion

Keywords: Intracerebral hemorrhage, ICH, hematoma expansion, prediction score, BAT score (PubMed Search)

Posted: 5/9/2018 by WanTsu Wendy Chang, MD (Updated: 11/28/2020)
Click here to contact WanTsu Wendy Chang, MD

Takeaways

  • CT angiography (CTA) spot sign is a strong predictor of intracerebral hemorrhage (ICH) expansion.
  • However, since CTA is not part of the routine diagnostic workup of acute ICH, other predictors using noncontrast head CT have been reported in the past.
  • A 5-point BAT score can be used to identify patients at high risk of hematoma expansion:

  •  
  • Patients with a score ≥ 3 have a higher risk of hematoma expansion

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Category: Geriatrics

Title: Pneumonia in the Elderly (Submitted by Dr. Amal Mattu)

Keywords: pneumonia, infection, delirium, atypical (PubMed Search)

Posted: 5/6/2018 by Danya Khoujah, MBBS
Click here to contact Danya Khoujah, MBBS

- Half of elderly patients presenting with pneumonia will manifest signs of delirium

- Tachypnea is the most reliable and earliest vital sign abnormality

- Classic symptoms are not often helpful at predicting severity of illness

- Symptoms are unreliable

- Cough (63-84%)

- Dyspnea (58-74%)

- Fever by history (53-60%)

- Fever at arrival (12-32%)

- Pleuritic chest pain (8-32%)

- Sputum (30-65%)

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Category: Pediatrics

Title: Nursemaid's Elbow Reduction Methods

Keywords: supination with flexion, hyperpronation (PubMed Search)

Posted: 5/4/2018 by Sarah Kleist, MD
Click here to contact Sarah Kleist, MD

Takeaways

Nursemaid’s elbow is a common pediatric injury with peak incidence occurring between two and three years of age.  It is a condition that typically arises from a sudden upward pull of the arm as an axial traction is placed on the forearm, and the radius is pulled through the annular ligament, resulting in subluxation of the radial head. Over the years, various maneuvers have been attempted, but the two most common are supination with flexion and hyperpronation. A 2017 Cochrane meta-analysis analyzed 8 trials specifically comparing supination with flexion versus hyperpronation.  Data from those trials suggested that hyperpronation resulted in less failures at ?rst attempt than the supination-?exion, and although there was limited data, there was no obvious difference in adverse events or pain between the two techniques.

Bottom Line: There is likely a lower risk of failure with first attempt reduction with hyperpronation than with supination-flexion for nursemaid’s elbow.

 

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Despite initial excitement for the use of intravenous lipid emulsion (ILE) therapy as an antidote for serious poisonings due to lipohphilic drugs there remains an absence of evidence combined with an incomplete understanding of its efficacy, mechanisms of action, safety, and analytical interferences to recommend its use except in a few clinical scenarios.

The lipid emulsion workgroup performed a comprehensive analysis of four systematic reviews and based recommendations from consensus of expert panelists from the American Academy of Clinical Toxicology, the European Association of Poison Centres and Clinical Toxicologists, the American College of Medical Toxicology, the Asia Pacific Association of Medical Toxicology, the American Association of Poison Control Centers, and the Canadian Association of Poison Control Centers. Toxins evaluated had to have a minimum of three human cases reported in the literature.They concluded that ILE could be indicated for the following clinical situations:

  •  In Bupivacaine poisoning resulting in cardiac arrest or life threatening toxicity (dysrhythmias, VTach  with compromised organ perfusion, VFib, status epilepticus, and/or hypotension with organ compromise defined as  increased lactate concentration, acute kidney injury, increased troponin, altered mental status, or decreased capillary refill) ILE is recommended after standard ACLS is started  and if other therapies fail or as last resort.
  • In life-threatening toxicity due to other local anesthetics,  ILE recommended if other therapies fail/in last resort
  • In cardiac arrest due to toxicity from Amitriptyline (or other tricyclic antidepressants), lipid soluble and non-lipid soluble Beta-receptor antagonists,  Bupropion, Calcium channel blockers (diltiazem, verapamil and dfihydropyridines), Cocaine, Diphenhydramine, Lamotrigine,  Baclofen, Ivermectin and other Insecticides, Malathion and other Pesticides, Olanzapine and other Antipsychotics, and SSRIs.
  • Most common regimen of ILE was a bolus of 1.5 mL/kg of ILE 20% followed by infusion of 0.25 mL/kg/min
  • The use of ILE with extracorpeal membrane oxygenation may cause fat deposition in the circuit and increase blood clot formation causing malfunction and limitation of use of this potentially life saving modality. This should be considered if VA-ECMO is a treatment option.

 

The Bottom Line:

The use of Intravenous Lipid Emulsion in severe poisoning is recommended only for a few poisoning scenarios and was based on very low quality of evidence, and consideration of risks and benefits, adverse effects, laboratory interferences as well as related costs and resources.

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DOACs and the Critically Ill

  • The use of DOACs for the prevention of stroke and venous thromboembolism is increasing.
  • Though DOACs may be non-inferior to warfarin for these indications, it is important to consider the following pearls on DOACs in the critically ill patient:
    • Acute kidney injury can double the half-life of dabigatran to more than 30 hours
    • Hepatic failure can markedly increase the half-life of the factor Xa inhibitors
    • PT, aPTT, and INR may not accurately assess the risk of bleeding. Use dilute thrombin time (TT), ecarin clotting time (ECT), or TEG/ROTEM to assess coagulopathy
    • Can consider PCC (25 to 50 IU/kg) for life-threatening hemorrhage. The evidence supporting this recommendation is not robust.

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Category: Orthopedics

Title: Exercise talking points for the pregnant patient

Keywords: Pregnancy, sports medicine (PubMed Search)

Posted: 4/28/2018 by Brian Corwell, MD (Updated: 11/28/2020)
Click here to contact Brian Corwell, MD

Exercise talking points for the pregnant patient

(from ACSM 2017 Consesnsus statement)

 

Exercise throughout pregnancy is generally safe but should be monitored

No evidence of higher rates of preterm or prolonged labor, or deliveries that require induction or episiotomy

No evidence of negative effect on APGAR scores

Other benefits:

Avoidance of excessive weight gain, improved balance, and decreased back pain

Improved well-being, energy levels, and sleep patterns

Improved labor symptoms and facilitation of post-partum recovery

Lower risk of C-section

Reduced risk of having a large for gestational age (LGA) or small for gestational age (SGA) infant

Risks include environmental exposure, dehydration, hypoxia, and uterine trauma:

High impact or high-strain physical activity during the fetal implantation phase may lead to slightly higher risk of miscarriage

Sports with high risk of trauma last in pregnancy could result in placental abruption

Scuba diving is contraindicated because the fetus is not protected from decompression problems

Limit use of sauna or hot tub to fewer than ten minutes or omit altogether

 

 

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Non-pharmaceutical fentanyl (NPF) is a major contributor to opioid overdoses and overdose fatality. In certain urban areas such as Vancouver, over 80% of heroin samples contain NPF.  For isolated heroin overdose ED patients, they can be safely discharged after brief observation period (~2 hours). However,  “safe” observation time for fentanyl is unknown.

Recently, a retrospective study evaluating the safe observation period in 1009 suspected (uncomplicated) fentanyl overdose ED visits (827 unique patients).

Results:

 In the field:

  • 476 (47.1%) received bystander naloxone
    • 422 (44.1%) had field GCS of 15
    • 547 (57.2%) had pulse oximetry of >= 95%.
  •  EMS administered naloxone to 546 (57.1%) patients (mean dose 0.4 mg IV)

In the ED:

  • 16 patients received additional naloxone in the ED
  • Mean length of stay: 173 minutes (IQR: 101 to 267 minutes)
  • 90% of the patients were discharged within 380 minute.
  • One patient was admitted and one patient died after discharge within 24 hours.

Conclusion:

  • Majority of the patients were safely discharged after 3 - 4 hours after receiving naloxone and if able to maintain GCS 15 with oxygen level 95% while able to ambulate normally.
  • However, some patient may require up to 6 hours of observation.  

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Category: Critical Care

Title: Predicting Failure of Non-invasive Ventilation and High Flow Nasal Cannula

Keywords: acute hypoxic respiratory failure, intubation, noninvasive positive pressure ventilation, high flow nasal cannula, BiPAP, vapotherm (PubMed Search)

Posted: 4/25/2018 by Kami Windsor, MD
Click here to contact Kami Windsor, MD

ED physicians frequently utilize modailities such as noninvasive positive pressure ventilation (NIV) and high flow nasal cannula (HFNC) to support and potentially avoid intubation in patients presenting with acute hypoxic respiratory failure. Unfortunately, failure of these measures, resulting in "delayed" intubation, has been associated with increased mortality.1,2

A recent post-hoc analysis of data from a multicenter randomized controlled trial evaluated 310 patients with acute hypoxic respiratory failure managed with supplemental O2 by regular nasal cannula, HFNC, or NIV.3

The following factors were predictive of eventual intubation in the different groups: 

  • For nasal cannula patients, RR > 30 at 1 hour
  • For HFNC patients, tachycardia at 1 hour (No respiratory variables were found to predict intubation).
  • For NIV patients, tidal volume > 9ml/kg predicted body weight or PaO2:FiO2 ratio < 200 at 1 hour

Of note, 45% of the 310 patients eventually required intubation, and these patients in general had a higher initial respiratory rate and lower PaO2 at presentation, and were more likely to have bilateral infiltrates on CXR. 

Bottom Line: Reevaluate your patients frequently. If RR remains high, P:F ratio remains low, or patient respiratory effort/work of breathing is not alleviated by noninvasive measures, consider pulling the trigger on intubation earlier.

 

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