UMEM Educational Pearls

Signs and symptoms of acute cyanide poisoning are not well characterized due to its rare occurrence.  Commonly mentioned characteristics of bitter almond odor and cherry red skin have poor clinical utility.

Recently published review of 65 articles (102 patients) showed that most patients experienced following signs and symptoms:

  1. Unresponsive: 78%
  2. Respiratory failure: 73%
  3. Hypotension: 54%
  4. Cardiac arrest: 20%
  5. Seizure: 20%
  6. Cyanosis: 15%
  7. Odor: 15%
  8. Cherry red skin: 11%

There is no clear toxidrome for cyanide poisoning.

In a poisoned patient, health care providers should consider cyanide in their differential diagnosis in the presence of severe metabolic and lactic acidosis (lactic acid > 8 in isolated cyanide poisoning or > 10 in smoke/fire victim).

Show References


Contrary to a popularly held belief that one can estimate the age of a bruise by its color, present day research found that the color of a bruise at the time of its initial appearance is unpredictable. It is also affected by medications.
Take Home: Do not assumptions about the age of the bruise based on the color.

Show References


Category: Pharmacology & Therapeutics

Title: Fosfomycin for UTIs

Keywords: Fosfomycin, urinary tract infection, cystitis (PubMed Search)

Posted: 3/3/2018 by Wesley Oliver
Click here to contact Wesley Oliver

Fosfomycin is an antibiotic infrequently used for the treatment of urinary tract infections (UTIs). It has a broad spectrum of activity that covers both gram-positive (MRSA, VRE) and gram-negative bacteria (Pseudomonas, ESBL, and carbapenem-resistant Enterobacteriaceae), which is useful in the treatment of multidrug-resistant bacteria. 

Fosfomycin is FDA approved for the treatment of uncomplicated UTIs in women due to susceptible strains of Escherichia coli and Enterococcus faecalis (3g oral as a single dose). Data has also demonstrated that it can be used for complicated UTIs; however, dosing is different in this population (3 g oral every 2-3 days for 3 doses).  Fosfomycin is not recommended for pyelonephritis.

The broad spectrum of activity, in addition to only needing a single dose in most cases, makes fosfomycin an attractive option; however, it should be reserved for use in certain circumstances.  Fosfomycin should not be considered as a first-line option.  It is also more expensive than other medications (~$100/dose) and in countries with high rates of utilization bacteria are developing resistance to fosfomycin.  In addition, most outpatient pharmacies do not keep this medication in stock.

Take-Home Point:

Fosfomycin should be reserved for multidrug-resistant UTIs in which other first-line options have been exhausted.

Show References


A leading cause of cardiac arrest in patients 40 years and younger is due to drug poisoning.  Adverse cardiovascular events (ACVE) such as myocardial injury (by biomarker or ECG), shock (hypotension or hypoperfusion requiring vasopressors), ventricular dysrhythmias (ventricular tachycardia/fibrillation, torsade de pointes), and cardiac arrest (loss of pulse requiring CPR) are responsible for the largest proportion of morbidity and mortality overdose emergencies. Clinical predictors of adverse cardiovascular events in drug overdose in recent studies include:

  • QTc prolongation on presentation ECG ( > 500 msec )
  • Prior history of either coronary artery disease or congestive heart failure
  • Metabolic acidosis (elevated serum lactate)

 

Bottom line:

Obtain ECG and perform continuous telemetry monitoring in overdose patients with above risk factors. Patients with two or more risk factors have extremely high risk of in-hospital adverse cardiovascular events and intensive care setting should be considered.

 

 

Show References


Category: Neurology

Title: Headache in the Bodybuilder

Keywords: headache, steroids, bleed (PubMed Search)

Posted: 2/28/2018 by Danya Khoujah, MBBS
Click here to contact Danya Khoujah, MBBS

Benign headaches are common in bodybuilders. However, several less benign headaches are worth noting:

  • Low cerebrospinal fluid (CSF) pressure headache: caused by a small dural tear mostly at the thoracic level. Similar to postdural headache. Treated by recumbency, and blood patches if recalcitrant.
  • Subarachnoid hemorrhage (SAH)
  • Spontaneous intracranial hemorrhage
  • Ischemic stroke
  • Dural sinus thrombosis

All except the first two are exclusively reported in patients on anabolic steroids, growth hormone, and/or “energy” supplements. Make sure to ask your patient about these risk factors.

 

Show References


Category: Critical Care

Title: Empiric Antifungal Therapy in Septic Shock

Keywords: ICU, fungal infection, septic shock, antifungal therapy, empiric (PubMed Search)

Posted: 2/27/2018 by Kami Windsor, MD
Click here to contact Kami Windsor, MD

Takeaways

Which septic patients should receive empiric antifungal therapy?

Patients with fungemia only make up about 5% of patients presenting with septic shock, but invasive fungal infections are associated with increased hospital mortality (40-50%), prolonged ICU and hospital length of stay, and increased costs of care.1

The EMPIRICUS trial showed no mortality benefit to empiric antifungals for all, even patients with candidal colonization and recent exposure to antibiotics.2

Bottom Line

Therapy should always be tailored to the specific patient, but providers should strongly consider admininistering empiric echinocandin (micafungin, caspofungin) over fluconazole in patients with severe sepsis/septic shock and:

  • Immunosuppression (chronic steroids, neutropenia, organ transplant)
  • Prolonged central venous catheters
  • TPN
  • Yeast colonization
  • Severe pancreatitis
  • Recent abdominal surgeries or procedures (perforation repairs, resections, etc.) or concern for impaired gut integrity

*Especially consider addition of antifungal in patients who do not show improvements after initial management with IVF and broad spectrum antibiotics in the ED.*

Show More In-Depth Information

Show References


Category: Orthopedics

Title: New blood test for concussion

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

Posted: 2/25/2018 by Brian Corwell, MD (Updated: 11/28/2020)
Click here to contact Brian Corwell, MD

The search for an objective reliable test for mild traumatic brain injury found an early promising result last week.

               May be arriving in your hospital in the near future.

               A handheld sideline version is sure to follow

The FDA approved the first blood test for concussion/mild TBI

               Called the Banyan BTI (Brain Trauma Indicator)

This test measures 2 neural protein biomarkers released into the blood following mild TBI

The FDA approved this test within 6 months after reviewing data on just under 2,000 blood samples.

               They concluded the Banyan BTI can predict the absence of cranial CT lesions with an accuracy greater than 99% and may reduce imaging in up to a 1/3rd

Be optimistic but consider the small sample size and remember that this test looks for biomarkers and may miss subtle cases where proteins didn’t leak. This test is NOT ready to be used for return to play decisions. It takes 3 to 4 hours to result and costs about $150. Other biomarkers are being investigated and may prove to be better

 

https://www.fda.gov/newsevents/newsroom/pressannouncements/ucm596531.htm

 


Category: Toxicology

Title: Toxin-induced nystagmus

Keywords: nystagmus, toxic (PubMed Search)

Posted: 2/22/2018 by Hong Kim, MD, MPH
Click here to contact Hong Kim, MD, MPH

Abnormal ocular movement (e.g. nystagmus) can often be observed in select CNS pathology.

Certain drugs/toxin overdose can also induce nystagmus.

  • Anti-epileptics: carbamazepine, lamotrigine, topiramate, phenytoin
  • Ethanol
  • Ketamine, phencyclidine (PCP), dextromethorphan – vertical or rotary nystagmus
  • Serotonergic syndrome/5-HT agonists – opsoclonus
  • Monoamine oxidase inhibitors – ping-pong nystagmus
  • Lithium
  • Scorpion envenomation 

In an "unknown" intoxication, physical exam findings such as nystagmus may help narrow the identity of the suspected ingestion/overdose.


-Nonischemic cardiomyopathy, classically seen in post-menopausal women preceded by an emotional or physical stressor

-Named for characteristic appearance on echocardiography and ventriculography with apical ballooning and contraction of the basilar segments of the LV – looks like a Japanese octopus trap or “takotsubo" (pot with  narrow neck and round bottom)

-Clinical presentation usually similar to ACS with chest pain, dyspnea, syncope, and EKG changes not easily distinguished from ischemia (ST elevations – 43.7%, ST depressions, TW inversions, repol abnormalities) and elevation in cardiac biomarkers (though peak is typically much lower than in true ACS)

 

** Diagnosis of exclusion – only after normal (or near-normal) coronary angiography **

 

-Care is supportive and prognosis is excellent with full and early recovery in almost all patients (majority have normalization of LVEF within 1 week)

-Supportive care may include inotropes, vasopressors, IABP, and/or VA ECMO in profound cardiogenic shock

 

** LVOT Obstruction **

-occurs in 10-25% of patients with Takotsubo’s cardiomyopathy

-LV mid and apical hypokinesis with associated hypercontractility of basal segments of the LV predisposes to LV outflow tract obstruction

-Important to recognize as it is managed differently:

            -may be worsened by hypovolemia, inotropes, and/or systemic vasodilatation

            -mainstay of treatment is avoidance of the above triggers/exacerbating factors while increasing afterload

                    *phenylephrine is agent of choice +/- beta blockade 

 

 

Take Home Points:

***Diagnosis of exclusion!!! Presentation very similar to ACS and ACS MUST be ruled out

* Treatment is supportive and similar to usual care for cardiogenic shock. Can be severe and require mechanical circulatory support!

*10-25% have LVOT obstruction. Manage with phenylephrine +/- beta blockade

Show References


Question

75 y/o M is brought in by EMS after he fell off the light rail and hit his head. In the ED he is A&Ox3, and is asking for a urinal. Two minutes later the tech comes running to show you the following:

What is the cause of this patients Jolly Rancher Green Apple looking urine sample? 

Show Answer


Category: Pediatrics

Title: What is the diagnosis?

Keywords: foreign body, choking (PubMed Search)

Posted: 2/16/2018 by Jenny Guyther, MD
Click here to contact Jenny Guyther, MD

Question

Patient: 11 month old with trouble breathing and color change after a family member sprayed air freshener.  Symptoms have since resolved.

What are you concerned about in the attached xrays?

Show Answer

Show References


Attachments

11_mo_lung_FB_word.docx (408 Kb)


Category: Toxicology

Title: Bupropion Cardiotoxicity

Keywords: Cardiotoxicity, Bupropion, Ventricular dysrhythmia (PubMed Search)

Posted: 2/15/2018 by Kathy Prybys, DO
Click here to contact Kathy Prybys, DO

Bupropion (Wellbutrin, Zyban) is unique monocyclic antidepressant and smoking cessation agent that is structurally similar to amphetamines.  Bupropion blocks dopamine and norepinephrine reuptake and antagonizes acetylcholine at nicotinic receptors.

  • One of the most common causes of drug-induced seizures.
  • Sinus tachycardia is the most frequently seen cardiac effects with overdose.
  • QTc prolongation and ventricular dysrhythmias can occur in severe overdose. New evidence supports this is not related to cardiac sodium channel block but likely due to blockade of the delayed rectifying (ikr) potassium channel and gap junction inhibition in the myocardium simulating effects class IA effect.

 

Bottom line:

Bupropion is a common cause of drug induced seizures but in severe overdose can also cause prolonged QTc and wide complex ventricular dysrhythmia that may be responsive to sodium bicarbonate. All patients with an overdose of bupropion should have an ECG performed and cardiac monitoring to watch for conduction delays and life-threatening arrhythmias.

 

 

 

Show References


Category: Neurology

Title: Occipital Nerve Block for Migraine?

Keywords: occipital nerve block, migraine, headache (PubMed Search)

Posted: 2/14/2018 by WanTsu Wendy Chang, MD (Emailed: 2/15/2018) (Updated: 2/15/2018)
Click here to contact WanTsu Wendy Chang, MD

  • Greater occipital nerve (GON) block with local anesthetics is an alternate treatment option for headaches.
  • Zhang et al. conducted a systematic review and meta-analysis of 7 randomized controlled trials assessing the efficacy of GON block for migraine.
  • Pooled outcome suggests that GON block: 
    • Reduces pain intensity (mean difference -1.24 [-1.98, -0.49], p=0.001)
    • Decreases analgesia medication consumption (mean difference -1.10 [-2.07, -0.14], p=0.02)
    • Has no significant impact on headache duration (mean difference -6.96 [-14.09, 0.18], p=0.06)

Show References


Category: Orthopedics

Title: Femoral neck stress fracture

Keywords: Hip pain, athletes (PubMed Search)

Posted: 2/10/2018 by Brian Corwell, MD (Updated: 11/28/2020)
Click here to contact Brian Corwell, MD

Femoral neck stress fractures

Adults>kids

Represents 5% of all stress fractures

Usually due to repetitive abductor muscle contraction

As with all stress fractures can occur in 2 types

1)      Insufficiency type (normal physiologic stress on abnormal bone)

2)      Fatigue type (abnormal/excessive physiologic stress on normal bone)

2 locations on interest:

1)      Compression side (inferior femoral neck)

2)      Tension side (superior femoral neck)

History: Insidious onset of groin or lateral hip pain associated with weight bearing

Exam: Antalgic gait, pain with hip log roll and with FABER (hip flexion, Abduction and external rotation test)

Treatment:

Compression side: reduced weight bearing and activity modification

Tension side:  Non weight bearing (due to high risk of progression to displacement with limited weight bearing) AND surgical consultation for elective pinning to prevent displacement. If displaced, will require ORIF

Show References


Category: Pediatrics

Title: Mucositis... when the shoe doesn't fit (submitted by Alexis Salerno, MD)

Keywords: Kawasaki's disease, SJS, TEN, dermatitis (PubMed Search)

Posted: 2/9/2018 by Mimi Lu, MD
Click here to contact Mimi Lu, MD

Question

Case:  5 year old presents to the ED with 2 weeks of fever. She has extensive cracked, bleeding lips and a rash on her hands and feet. She was recently diagnosed with “walking pneumonia” and hand, foot and mouth disease this week. Her pediatrician sent her in for further workup after she was found to have an elevated CRP on outpatient labs. A similar picture appears in the link below:

http://www.eblue.org/cms/attachment/2024057003/2043959646/gr1_lrg.jpg.

What's the diagnosis?

 

Show Answer


Hyperoxia and the Post-Arrest Patient

  • Current post-arrest guideilnes recommend titrating supplemental O2 to avoid hypoxia and limit exposure to hyperoxia.
  • Importantly, these recommendations are based primarily on retrospective studies that have used ABG values within the first 24 hours following ROSC.
  • The latest study to evaluate the impact of hyperoxia following cardiac arrest was just published in Circulation
  • This study is a prospective, cohort study that evaluated the association between early hyperoxia and poor neurologic outcome in adults following cardiac arrest. (ABGs were obtained at 1 hour and 6 hours following ROSC)
  • Of 280 patients, 38% were exposed to early hyperoxia (defined as a PaO2 > 300 mm Hg)
  • Take Home Points
    • Early hyperoxia was found to be an independent predictor of poor neurologic outcome at hospital discharge.
    • One hour longer duration of hyperoxia was associated with a 3% increase in the risk of poor neurologic outcome
    • SaO2 could not reliably exclude the presence of hyperoxia.

Show References


Category: Geriatrics

Title: Geriatric Dizziness (Submitted by: Dr. Katherine Grundmann)

Keywords: dizziness, CT, MRI, Cerebellar (PubMed Search)

Posted: 2/5/2018 by Danya Khoujah, MBBS (Updated: 11/28/2020)
Click here to contact Danya Khoujah, MBBS

15% of older adults presenting to ED for dizziness have serious etiologies; 4-6% are stroke-related and sensitivity of CT for identifying stroke or intracranial lesion in dizziness is poor (16%), so if CNS etiology suspected, seek neuro consult or MRI (83% sensitivity)

 

Show References


Takeaways

Debating between cefepime or piperacillin/tazobactam for your septic patient? Use this table to help you decide.

 

 

Cefepime

Piperacillin/Tazobactam

Gram Negative Spectrum

Pseudomonas aeruginosa 

Yes

Yes

Aerobic gram negative organisms 

E. coli 

Klebsiella sp. 

Proteus mirabilis 

M catarrhalis  

H. influenza 

E. coli 

Klebsiella sp. 

Proteus mirabilis 

M. catarrhalis 

H. influenza 

Anerobic gram negative organisms 

No

B. fragilis 

 

Gram Positive Spectrum

MRSA 

No

No

Aerobic gram positive organisms 

MSSA 

CoNS 

Group A Strep 

S. pneumoniae 

 

MSSA 

CoNS 

Group A Strep 

S. pneumoniae 

E. faecalis 

Anaerobic gram positive organisms 

P. acnes 

Peptostreptococci 

P. acnes 

Peptostreptococci 

Clostridium sp. 

Infection Site Concerns

CNS Penetration 

Yes

No1

Urine Penetration 

Yes

Yes

Lung Penetration 

Yes

Low2

Dosing Frequency (Normal Renal Function)

Q8h 

Q6h 

1Tazobactam CNS penetration is limited, thus limiting antipseudomonal activity in the CNS 

2. Low pulmonary penetration, may not achieve therapeutic levels in patients with critical illness 

 

Show More In-Depth Information

Show References


Category: Pediatrics

Title: Name that Belly Pain!

Keywords: Pediatrics, Abdominal Pain (PubMed Search)

Posted: 2/2/2018 by Megan Cobb, MD
Click here to contact Megan Cobb, MD

Question

Your patient is an18 months old female with intermittent abdominal pain for the last 4-5 days. She has history of constipation and soy allergy, seen at an outside hospital three days ago for the same. She had an xray and was discharged home with instructions for at home clean out with diagnosis of constipation. 

Mother is bringing her to your ED because the pain is back. The laxatives helped somewhat, but her symptoms have returned. She reports that the patient cries spontaneously, lasting 1-2 minutes, then completely resolves. These episodes happen at multiple times during the day. 

ROS: Decreased appetite and energy, but NO fevers, vomiting, diarrhea, bloody stool, abdominal distension, hematuria, or lethargy. 

Show Answer

Show References


Attachments

Colicky2018.jpg (100 Kb)


Category: Toxicology

Title: Perils of OTCs

Posted: 2/1/2018 by Kathy Prybys, DO (Emailed: 2/2/2018) (Updated: 2/2/2018)
Click here to contact Kathy Prybys, DO

Question

47 year old woman presents with cough, headache, weakness, and low grade fever. Her symptoms have been present for several days. Vital signs are temperature 99.9 F, HR 96, RR 16, BP 140/88, Pulse Ox 98%.  Physical exam is nonfocal. She is Influenza negative. She is treated with Ibuprofen and oral fluids.  Upon discharge she mentions she is having difficulty hearing and feels dizzy. Upon further questioning she admits to ringing in her ears. What tests should you order?

Show Answer

Show References