UMEM Educational Pearls

Care of the Crashing Asthma Patient

Several things should be considered in the crashing asthmatic:

• First and foremost, there is very little date on how to manage the crashing asthmatic!
• Any sick asthma patient should have IV fluid replacement-these patients have tons of insensible losses. IV fluids may also help with post-intubation hypotension cause by compression of the vena cava.
• Many EM folks have left Ketamine in the dust for intubating an asthmatic....anecdotally, it works, but creates very sticky and tenacious lung boogers that are hard to suction. Why make your job even harder?
• Sounds like common sense, but RSI the patient in the position of comfort (usually tripod) and then quickly lay them back supine.
• Consider instituting the "kitchen sink approach" to asthma care. This includes beta agonists, anticholinergics, Mg, steroids, IVF, epi, nebulized Lidocaine, perhaps non-invasive ventilation, inhaled (yes, inhaled) steriods. Our job really begins once they have been tubed.
• Sounds corny, but consider a "bedside coach." Believe it or not, some really sick asthmatics can be talked through a severe, life-threatening exacerbation. This can be a nurse, tech, physician. Someone to talk to them during this crisis. It works sometimes.
• Any intubated asthmatic who goes into PEA arrest should not be declared dead unless bilateral needle decompressions and bilateral chest tubes have been performed.
• If an intubated asthmatic codes once intubated, consider the following: (1) disconnect from the ventilator and bag VERY slowly...4-6 breaths/minute or even slower! (2) Although controversial, some consider manual chest wall compression helpful in "getting rid" of trapped air. (3) Vigorous IVF-positive pressure ventilation worsens the patients hyperinflation which compresses the vena cava, and (4) consider needle decompression and then chest tube insertion

Adenosine should never be used in the setting of a wide complex regular tachycardia as a diagnostic maneuver. Adenosine will convert some types of VT, and this may mislead the health care provider into thinking that the WCT is an SVT. The electrophysiology literature is rife with reports of "adenosine-sensitive VT," and these patients are often young and without prior history of CAD...the very patients that we'd most be inclinded to assume have SVT.

The bottom line is that one should always assume that a regular WCT (without obvious evidence of sinus tachycardia) is VT, and treat the tachydysrhythmia as such.

Most of use remember that Fifth disease is a viral infection presenting with a distinctive rash (slapped check) caused by Parvovirus B19.  But do you know the numbering of the other six Contagious Illnesses that are associated with rashes:

1. First Disease – Measles caused by the rubeola virus
2. Second Disease – Scarlet Fever caused by Streptococcus pyogenes Group A
3. Third Disease – German Measles caused by rubella virus
4. Fourth Disease – Dukes Disease – In the late 1880-1900’s it was widely published about but in the 1960’s it was not proven to exist by either epidemiologic criteria or isolation of an etiologic agent.  Now felt to be a mild form of scarlet fever.  Some reports of it being caused by a Coxsackvirus or Echovirus
5. Fifth Disease - Erythema infectiosum caused by Parvovirus B19. Slapped Check
6. Sixth Disease - Exanthem subitum (meaning sudden rash), also referred to as roseola infantum (or rose rash of infants), sixth disease. Presents as rapid onset high fever, followed by a fine red rash when the fever subsides. Caused by Herpes Virus 6.

Febrile Seizures

• Diagnosis: Simple vs Complex
  • Simple Febrile Seizure
    • Age = 6mos to 5yrs
    • Single Seizure
    • Generalized
    • Lasting less than 15 minutes
    • Child returns to baseline and has normal neurological exam.
  • Complex Febrile Seizure
    • Same as above, except can be focal seizure or prolonged or with multiple seizures within 24 hours.
    • May indicate a more serious disease process.

• Etiologies:
  • Viral illnesses are the predominant cause of febrile seizures.
    • Human herpes simplex virus 6 (HHSV-6) has been associated with about 20% of pts with first febrile seizures.
  • Shigella gastroenteritis also has been associated.
  • The rate of serious bacterial infections is similar to those found in pt’s with fever without a source

• Key Point:
  • Do NOT forget to work-up the fever as you would for the patient’s age!
  • A lower threshold for performing full-sepsis work-up with LP is advocated in those pt’s less than 12 months of age.
     

Here are a couple of herbals touted as aphrodesiac's and the toxcity associated with them (the price of love):

Chan Su or "Love Stone" - A chinese herbal that is suppose to be topically applied, unfortunately all of the instructions are in chinese and those who ingest it will die a digoxin-like death. It has a compound that is essentially a potent digoxin-like substance.

Yohimbine - herbals that contain this can cause priapism -  shocker

• The brainstem is the lower extension of the brain that connects the brain to the spinal cord.

• Neurological functions located in the brainstem include those necessary for survival (breathing, digestion, heart rate, blood pressure) and for arousal (being awake and alert).

• Most of the cranial nerves come from the brainstem.  The brainstem is the pathway for all fiber tracts passing up and down from peripheral nerves and spinal cord to the highest parts of the brain.

Spontaneous Pneumomediastinum

• Spontaneous pneumomediastinum is largely a benign disease typically seen in young males ages 18-21 years
• It is typically caused by activities that increase alveolar pressure such as coughing, sneezing, vomiting, inhalational drug use, and Valsalva maneuver
• The most common symptoms include chest pain and dyspnea; chest pain is usually centrally located, may radiate to the neck, and may be worse with inspiration
• CT scan is the "gold standard"; CXR is a good place to start but it is normal in up to 30% of cases
• The vast majority of patients do not require admission or supplemental O₂
• Advise patients to avoid strenuous activity until after symptom resolution (typically takes about 2 weeks)
• Any patient with a fever, elevated WBC count, hemodynamic instability, severe dysphagia or odynophagia should first be evaluated for infectious mediastinitis or esophageal perforation (spont. pneumomediastinum is a diagnosis of exclusion in these patients)

AAA...be afraid, be very afraid

Abdominal Aortic Aneurysm (AAA)  is known as the great masquerader in the elderly for good reason....

• May look EXACTLY like a kidney stone
• May cause vague abdominal and/or back pain....probably one of the reasons we scan older folks with abdominal pain. Presentations of AAA in the older patient may not be impressive!
• May be associated with the "blue toe syndrome" (where mural thrombus flips distally and occludes small vessels in the feet and toes)
• A pulsatile mass is frequently absent
• 10% of urology referrals for older (>65) patients with suspected kidney stones result in a diagnosis of AAA

The 5 most important factors at predicting the presence of ACS in a patient presenting with chest pain (in order of importance):
1. nature of anginal symptoms (i.e. the HPI)
2. prior history of CAD
3. male gender
4. older age
5. increasing number of traditional risk factors

Notice this means that the MOST important factor is the HPI...the OLDCAAAR. If the patient has a concerning HPI, NEVER drop your concerns just because the patient is young or has minimal other risk factors.

Rhogam 

• Remember to administer Rhogam to any Rh negative mother that has the following conditions:
• Pregnancy/delivery of an Rh-positive baby
• Abortion/threatened abortion at any stage of gestation
• Ectopic pregnancy
• Antepartum fetal-maternal hemorrhage (suspected or proven) resulting from antepartum hemorrhage (e.g., placenta previa), amniocentesis, chorionic villus sampling, percutaneous umbilical blood sampling, other obstetrical manipulative procedure (e.g., version) or abdominal trauma
• Transfusion of Rh incompatible blood or blood products (i.e.: platelets)

Dosing:

• 300 mcg IM
• Can give 50 mcg IM within 72 h of exposure of a therapeutic or spontaneous abortion if gestation age is 12 weeks or less. (Order as MICRhogam)
• Additional doses of Rhogam may be necessary when the patient has been exposed to > 15 mL of Rh-positive red blood cells. This may be determined by use of qualitative or quantitative tests for fetal maternal hemnorrhage but generally will only occur during a full term delivery or if incompatible blood products are given.

Trivial Fact: Rhogam is Pregnancy Class C

Neonate with Red Eye

• Crusty Eye – Not Red
  • Dacryostenosis - nasolacrimal duct obstruction
  • It is the most common cause of tearing in childhood.  
  • No photophobia, corneal is normal
  • Tx  = Warm compresses and gentle massage

• Purulent Conjunctivitis - Ophthalmia neonatorum
  • Chemical (due to prophylactic eye drops) - day 1
  • Gonorrhea –
    • Presents early on (day 2-5)
    • OCULAR EMERGENCY – may cause globe perforation
    • Associated Systemic Infection - meningitis
    • Ceftriaxone (25-50mg/kg) – Treat until Cx’s return.
  • Chlamydia –
    • Longer incubation period (day 5-14)
    • Causes Eyelid Scarring leading to blindness
    • Associated Systemic Infection – Pulmonary
    • Ceftriaxone (25-50mg/kg) + Topical Erythromycin
    • If Culture +, then PO erythromycin to prevent late onset pneumonitis.

• Remember that it is important to check a patient's peripheral vision when concerned about stroke, and when performing a neurological exam in general.
• Recognizing grossly abnormal peripheral vision often suggests the presence of various types of visual field cuts and helps localize a stroke lesion.
• When performing a general, very gross examination for peripheral vision abnormalities:

1. It is sometimes helpful to ask the patient to cover the eye that you are NOT checking for abnormality at the time.
2. Ask the patient to look straight ahead.
3. Ask the patient to tell you when they are able to see the long, narrow object (i.e. your finger, a pencil, etc.) that you slowly move forward into their view, starting from the point where the finger tips of the patient's laterally abducted arm would be (i.e. the object begins at a distance approximately equal to the patient's arm length).
4. Using this axis of reference, normal peripheral vision should occur at 45 degrees or less.

Physical Examination finding in inferior vena cava thrombosis

Consider IVC thrombosis if you ever see vertically oriented, dilated abdominal wall veins, or dilated veins on the back. As opposed to abdominal wall veins that radiate out from the umbilicus in patients with cirrhosis-known as caput medusae.

Etiologies include hepatic tumors abutting the IVC, renal cell tumors, open abdominal surgery, catheter related, IVC filter-related.

The ACC/AHA just recently published a "Focused Update" of their guidelines for management of ST-elevation MI. Amongst the changes:

Clopidogrel 75 mg per day orally should be added to aspirin in patients with STEMI who receive thrombolytics.

Clopidogrel 300-600 mg orally should be added to aspirin in patients that are going for PCI for STEMI. This is listed as a Class I intervention, although the level of evidence is rated "C." In other words, it is judged to be definitely helpful though based on not-so-robust evidence (you figure that one out!).

Glycoprotein receptor antagonists can also be added (Class IIa, level of evidence B).

[I personally believe there is better evidence for the GP2B3A inhibitors than for clopidogrel, but there is a general push for more and more guideline writers to support clopidogrel. The number of writers for these ACC/AHA guidelines who have affiliations with the drug companies, including the ones that manufacture clopidogrel (Plavix), is tremendous; the list of disclosures is listed at the back of the document. Nevertheless, people tend to want to follow guidelines, and the boards will test you on this stuff so it is worth knowing.]

[Also for the record, if I have a STEMI, here's what I want: 162 mg ASA (not 325 mg), unfractionated heparin (not enoxaparin), abciximab/ReoPro (not eptifibitide/Integrilin) in the cath lab (not in the ER), and quick PCI; if I can't get the PCI within 60 minutes (not 90, but 60 minutes!), give me either tenectaplase or retaplase (not tPA) + 162 mg ASA + UFH; if I have a lot of pain that is not responding to NTG, give me dilaudid or fentanyl (not morphine)...and some Bailey's on ice; add oral BBs, ACEIs, and a statin at the 24 hour mark, NOT any earlier (early BBs only if I have Bailey's-resistant hypertension). Thanks.]

Amal

 

We have seen this lovely  bug infect our patients and have to instutitue therapy. But do you know what is the first line drug and which one has now become second line due to its toxicity? Here is the short list:

First Line Therapy: Permethrin (Nix) - least toxic, only causes local irritation

Second Line Therapy: Crotamiton (Eurax) - again local irritation

Third LIne Therapy: Lindane - SEIZURES if you leave it on too long or put on too much. Children were particularly susceptible and relatively contraindicated.

Metacarpal Neck Fractures (i.e.: Boxer’s Fracture if 5^th Metacarpal)

Depending on the MCP joint involved a certain amount of angulation is permissible before it adversely affects normal function.

• 2^nd and 3^rd Metacarpal fractures < 10۫ angulation ideally these should be perfectly aligned.
• 4^th Metacarpal fracture <20۫ angulation allowed
• 5^th Metacarpal fracture <30۫ angulation. 
  • Studies have shown that even 30۫ angulation will decrease normal function by 20%.  
  • Normal excursion of the 5^th MCP is 15۫ to 25۫.
• No amount of rotation deformity should be allowed.

Tissue adhesives:

Cyanocrylate Tissue Adhesive is an excellent product to use when repairing linear lacerations.

A few things to remember:

The wound needs to be irrigated as you would any other wound prior to closure.

Gravity works.  Consider where the product may drip to before you apply it (Eyes, Ears, Nose, etc).  

Use Surgi-Lube (or other petroleum product) to create a barrier to limit the flow of the cyanocrylate.

For long lacerations, you may use steri-strips to help approximate edges before applying the tissue adhesive.

What to do if the glue gets out of control and drips onto the eyelids... may also apply to Krazy-Glue:

Use copious irrigation and then Mineral Oil (not acetone or alcohol - which won't go well in the eyes).

Often there will be an associated corneal abrasion... treat it as other corneal abrasion.

Here is a list of drugs that can cause hyperkalemia either at therapeutic levels or in overdose:

Amiloride, ACEI, Beta Blockers, Cardiac Glycosides, FLuoride

Heparin, NSAIDS, Penicillin (the Pen VK formulation), Spironolactone

Succinycholine and triamterene

• Dihydroergotamine (DHE) is an older medication approved for the treatment of intractable migraine and cluster headaches.  Many of our Neurology colleagues still use this drug and its administration could start while the patient is 
  in the ED.
  
• Intranasal forms have become popular (i.e. Migranal).  Intramuscular and subcutaneous administration are also possible.
  
• The typical intravenous dose is 0.25 to 1 mg IV push over 2-3 minutes q 6 hours for 24 to 72 hours.
  
• DHE use is contraindicated in the following patients: 
  
  >    Patients concurrently on a protease inhibitor or macrolide antibiotic because of increased risk of life- threatening peripheral ischemia (**Black Box Warning**) 
  >    Patients with a hypersensitivity to ergot alkaloids 
  >    Patients with increased risk of developing vasospastic events 
  >    Patients who are concurrently taking vasoconstrictors 
  >    Patients who are pregnant or nursing 
  >    Patients with hemiplegic or basilar migraines
  
• Monitor for the following potential adverse reactions, which are typically related to vasoconstriction/spasm
  and warrant immediate abortion of the drug’s administration: 
  
  >    Myocardial infarction (check ECG's)
  >    Arrhythmia (place on cardiac monitor)
  >    Stroke (regular neuro. checks)
  >    Hypertension (check often) 
  >    Ischemia (monitor for clinical signs/symptoms) 
  
  
  
  
  -- Diener HC, Kaube H, Limmroth V. A practical guide to the management and prevention of migraine. Drugs. 1998;56(5):811-824.
  -- Fisher M, Gosy EJ, Heary B, Shaw D. Dihydroergotamine nasal spray for relief of refractory headache: A retrospective chart review. Curr Med Res Opin. 2007;23(4):751-755.
  -- http://www.aetna.com/cpb/medical/data/400_499/0462.html
  -- http://www.rxlist.com/cgi/generic/dihyergmes.htm
  
   

Invasive Arterial Pressure Monitoring - Complications

In critically ill patients with hemodynamic instability we often place arterial catheters to continuously monitor mean arterial pressure.  Since we frequently use the radial artery for cannulation, it is important to know the complications associated with these catheters.  Scheer et al performed, perhaps, the largest review of complications of peripheral arterial catheters.  The results:

• Radial arterial catheters
  • 19,617 cannulations reviewed
  • temporary occlusions - 19.7%
  • hematoma - 14.4%
  • serious ischemic damage - 0.09%
  • pseudoaneurysm - 0.09%
  • sepsis - 0.13%

Pearl: Although permanent ischemic damage is rare, when placing a radial artery catheter use the non-dominant hand.

Scheer BV, Perel A, Pfeiffer UJ. Clinical review: Complications and risk factors of peripheral arterial catheters used for haemodynamic monitoring in anaesthesia and intensive care medicine. Crit Care 2002;6:198-204.