Question

When you look up dosing for levofloxacin for community acquired pneumonia (CAP), you will find that both of the following options are approved:

• Levofloxacin 500 mg IV/PO daily x 7-14 days
• Levofloxacin 750 mg IV/PO daily x 5 days

This is based on a multicenter, randomized, double-blind, active treatment trial comparing these two regimens in CAP (mild to severe). This non-inferiority trial shows that the 750 mg dose of levofloxacin for 5 days is "at least as effective and well tolerated" as the 500 mg dose of levofloxacin for 10 days.

So why should you choose the 750 mg daily x 5 day regimen?

• Higher doses maximize the concentration-dependent pharmacokinetic profile of the drug
• Higher doses and shorter duration may be associated with less drug resistance
• Patients subjectively report feeling better at day 3 with the higher dose regimen

As alway with levofloxacin, don't forget to renally dose adjust subsequent doses when writting a script or scheduled inpatient order for patients with reduced creatinine clearance! 

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  Black widow   spiders belong to the genus Latro dectus which include 31 species of widow spiders found throughout world. Approximately 1500-2500 black widow bites are reported to American poison control centers annually. A black widow can be identified by their hourglass pattern (red or orange) on the ventral aspect of their shiny globular abdomen. Fortunately, envenomation is rare but when it does occur it causes severe pain, muscle cramping, abdominal (may mimic acute abdomen) often refractory to traditional analgesics and antivenom (Antivenin Latrodectus mactans) is available and effective . Alpha-latrotoxin is the potent toxin causing presynaptic cation channels to open (calcium) and release of neurotransmitters such acetycholine. The neurological signs and symptoms caused by predominantly autonomic and include tachycardia and hypertension. The antivenom is equine based and infused over 20-30 minutes with pain relief in 20 minutes.

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1706300213_black_widow.jpg (3,059 Kb)

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Ventilation During Cardiopulmonary Resuscitation  

• Cardiopulmonary resuscitations are often highly stressful and chaotic situations.  As a result, it is no surprise that ventilation rates can be as high as 60 breaths per minute.  
• Hyperventilation during cardiopulmonary resuscitation can increase intrathoracic pressure, impair venous return, decrease coronary perfusion pressure, and ultimately decrease survival.
• It is imperative that the team leader pay close attention to ventilation and ensure that approximately 8 to 10 breaths per minute are delivered.
• Once ROSC is achieved, the respiratory rate should be adjusted to maintain a PaCO2 between 40 and 45 mm Hg.  

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Adhesive Capsulitis aka Frozen Shoulder

Spontaneous gradual onset stiffness and pain of the Glenohumeral joint

Shoulder capsule becomes thickened and contracted

Often affects patients between 40 and 60 years old

Left> Right shoulder

Women> men

Association with diabetes and thyroid disease

3 clinical stages

1)      Pain – gradual onset, diffuse, severe, disabling, often worse at night

2)      Stiffness – decreased ROM, affects ADLs, improved pain

3)      Thawing – gradual return of motion

Physical examination: Painful and decreased ROM. Evaluate active and passive movement, external rotation and ABduction of the shoulder most affected

Surgical or post traumatic shoulder stiffness usually resolves within 12 months.

Adhesive capsulitis is generally self-limiting lasting an average of 18-36 months.

DDX: Chronic locked posterior shoulder dislocation (VERY IMPORTANT), tumor.

Treatment: NSAIDs, Physical therapy, Intra articular steroids

If this fails, manipulation under anesthesia and/or arthroscopic surgical release

Question

Every year in the U.S., preventable poisonings in children result in more than 60,000 ED visits and around 1 million calls to poison centers.  Calls relating specifically to pet medication exposure and children have been on the rise.

A recent study in Pediatrics was the first was kind to characterize the epidemiology of such exposures.

This study is a call to arms for an increased effort on the part of public health officials, pharmacists, veterinarians, and physicians to improve patient education to prevent these exposures from occurring. 

Summary of major findings:

• Children less than or equal to age 5 are at greatest risk
• Ingestion accounted for the exposure route in 93% of cases. 
• Exploratory behavior(61.%) was the most common mechanism of exposure

Most commonly Implicated exposures:

• Pet medications with no human equivalent  (17.3%)
• Antimicrobials (14.8%
• Antiparasitic 14.6%)
• Analgesics (11.1%)

Key contributors to exposure risk:

• Lack of recognition by caregivers of potential hazards of pet medications
• Inappropriate or lack of home storage practices
• Inconsistent compliance by veterinary providers in terms of proper product labeling and child-resistant packaging

Take home point: Make sure your pet's medications are appropriately stored for safety!

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Question

Chest injuries represent the second most common cause of pediatric trauma related death.  ATLS guidelines recommend CXR in all blunt trauma patients.  Previous studies have suggested a low risk of occult intrathoracic trauma; however, these studies included many children who were sent home.

Predictors of thoracic injury include: abdominal signs or symptoms (OR 7.7), thoracic signs of symptoms (OR 6), abnormal chest auscultation (OR 3.5), oxygen saturation < 95% (OR 3.1), BP < 5% for age (OR 3.7), and femur fracture (OR 2.5).

4.3 % of those found to have thoracic injuries did not have any of the above predictors, but their injuries were diagnosed on CXR.  These children did not require trauma related interventions.

Bottom line: There were still a number of children without these predictors that had thoracic injuries, so the authors suggest that chest xray should remain a part of pediatric trauma resuscitation.

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Street names for illicit substance are diverse and unique. Knowing what your patient used prior to ED presentation can help with the management of their intoxication. 

DEA recently released 7 page list of common street names for drugs of abuse. 

https://ndews.umd.edu/sites/ndews.umd.edu/files/dea-drug-slang-code-words-may2017.pdf

But keep in mind that what our patients purchase and use may not actually contain the drug that they intended to purchase (e.g. fentanyl being sold as heroin).  

Attachments

1706051356_dea-drug-slang-code-words-may2017.pdf (2,993 Kb)

Question

What is the role of EEG for first-time seizures in the ED?

• Wyman and colleagues performed a prospective trial on the use of 30-minute routine electroencephalogram (EEG) in the ED after a first-time seizure or recurrent seizure without performance of a previous EEG to guide decision making in the initiation of antiepileptic medication.
• A diagnosis of epilepsy based on EEG findings was made for 21% of patients (n=15/71).
• Antiepileptic medication was initiated in 24% of patients (n=17/71), including 2 patients with abnormal but not epileptic EEG findings.

Take Home Point:  A 30-minute routine EEG in the ED in adults with an uncomplicated first-time seizure revealed a substantial number of epilepsy diagnosis and can change ED management with immediate initiation of antiepileptic medication.

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Question

In patients with persistent VT/VF cardiac arrest, giving epinephrine before the 2nd defibrillation attempt (which should follow initial shock and 2 minutes of CPR) is associated with decreased ROSC, decreased hospital survival, and decreased functional outcome. 

Take Home Point:

"Electricity before Epi" in patients with persistent VT/VF arrest, at least for the initial epinephrine dose.

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Shin Splints

Medial tibial stress syndrome (MTSS) aka shin splints is an overuse injury of the tibia

Very common

-10 to 15% of running injuries and over 50% of leg pain syndromes

3 Characteristics

1)      Pain along the posteromedial border of the tibia

2)      Diffuse pain

3)      Pain that is activity related

Risk  Factors

Female sex, increased weight, previous running injury, and

Higher navicular drop (amount of foot pronation) and

Greater hip external rotation with the hip in flexion

Differential  Diagnosis

Tibial stress fracture, compartment syndrome, nerve entrapment (sural), lumbar radiculopathy and popliteal artery entrapment. 

Question

A patient presents with altered mental status for unclear reasons- could it be anticholinergic syndrome? 

There are many medications (e.g. Beers Criteria, see pearl from March 5, 2017) and plants (e.g.: certain mushrooms) that can cause this life-threatening toxidrome.

The quick mnemonic for anticholinergic poisoning is:

·      Hot as a hare (hyperthermia)

·      Red as a beet (flushed)

·      Cry as a bone (decreased secretions)

·      Blind as a bat (mydriasis)

·      Mad as a hatter (delirium)

·      Full as a flask (urinary retention)

Bottom line: Keep anticholinergic syndrome within your differential for a patient with altered mental status without a clear cause.  

Note: An earlier version of this pearl incorrectly listed organophospahtes, which cause cholingeric toxicity.

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The poor sensitivity of bedside echocardiography to identify all-comers with pulmonary embolism is well documented. Most series cite a sensitivity and specificity of 31% to 72% and 87% to 98%, respectively (1,2). But as Nazerian et al demonstrate in their recent publication in Internal and Emergency Medicine, the diagnostic performance of bedside echocardiography is far more reliable in the subset of patients presenting in shock (3).

Of the 105 patients included in the final analysis, in 43 (40.9%) PE was determined to be the etiology of their shock. Bedside echo demonstrated notable diagnostic prowess when employed in this subset of patients, sensitivity (91%), specificity (87%), –LR (0.11), +LR (7.03). The sensitivity and –LR were further augmented when the venous US of the LE was included (sensitivity of 95% and –LR of 0.06) in the diagnostic workup. 

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Older patients with acute coronoary syndrome (ACS) are less likely to present with typical ischemic chest pain (pressure-like quality, substernal location, radiating to jaw, neck, left arm/shoulder and exertional component) compared with younger counterparts.

Typical angina symptoms predictive of acute myocardial infarction (AMI) in younger patients were less helpful in predicting AMI in the elderly population.

Autonomic symptoms such as dyspnea, diaphoresis, nausea and vomiting, pre-syncope or syncope are more common accompaniments to chest discomfort in elderly ACS patients.

Symptoms may also be less likely to be induced by physical exertion; instead, they are often precipitated by hemodynamic stressors such as infection or dehydration

Bottom Line: Keep a high index of suspicion for ACS in older patients as they present atypically.

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Question

• The incidence of Staphylococcus aurea as a urinary pathogen is increasing, however, this finding may represent more than a simple urinary tract infection.
• One review found an 8-21%rate of association between S. aureus in the urine with bacteremia.
• Additional work up, including blood cultures, may be warranted in patients with systemic symptoms, lack of access to follow up, and no urinary tract pathology or instrumentation.

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Post-partum hemorrhage results in approximately 100,000 deaths annually and is the leading cause of maternal death globally.

In a just published study in the Lancet, among approximately 20,000 women from 21 countries enrolled in the WOMAN study, death due to bleeding was significantly reduced in women given tranexamic acid (1.5%) compared to those in the placebo group (1.9%) {RR 0.81, 95% CI 0.65–1.00; p=0.045)}. This was especially true in women given tranexamic acid with 3 hours of giving birth (1·2%) vs in the placebo group (1·7%) {RR 0.69, 95% CI 0.52–0.91; p=0·008)}.

Bottom line:

The authors’ interpretation “Tranexamic acid reduces death due to bleeding in women with post-partum haemorrhage with no adverse effects. When used as a treatment for postpartum haemorrhage, tranexamic acid should be given as soon as possible after bleeding onset.”

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Distal Radius Fractures

High energy mechanism in younger patients

Falls more common in older patients

Higher incidence in older women due to osteoporosis

     May indicate overall poor bone health

  Avoid splinting in positions of flexion (palmer) and ulnar deviation

    Palmer flexed positions may have a higher rate of displacement

Non operative treatment

Extra-articular fx, less than 5mm shortening of radius, Less than 5 degrees of dorsal angulation.

     Consider fractures than are only stable in extreme positions to be unstable

If fx involves the ulnar styloid or DRUG (distal radial ulnar joint) place in long area posterior splint with arm in mid supination (anatomic position of forearm)

Question

Botulism is a rare neurologic condition characterized by GI symptoms that progressed to cranial nerve dysfunction and symmetric descending paralysis. Foodborne botulism is due to ingestion of botulinum toxin that is produced by clostridium botulinum, an ubiquitous bacterium in our environment. 

Bottom line:

• Foodborne botulism presents with GI symptoms that is followed by symmetric descending flaccid paralysis.
• Botulinum antitoxin prevents further progression of neurologic deficit; it does not reverse the neurologic deficit that is present prior to administration. 
• Contact your local poison center, and state health department & CDC regarding management and access to botulinum antitoxin.

Maryland Department of Health and Mental Hygiene

• During business hours: 410-767-6700
• After hours: 410-795-7365

CDC Emergency Operations Center: 770-488-7100

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Vasovagal syncope is a subtype of neurally mediated syncope, and it is distinctly different from orthostatic hypotension. 

Patients with orthostatic syncope have severe orthostatic hypotension that results in transient loss of consciousness immediately or within moments of standing up. This is different from neurally mediated syncope, which develops gradually under conditions of prolonged orthostatic stress such as standing for several minutes. Tilt table testing is useful for true orthostatic syncope, but not for neurally mediated syncope. In addition, checking for “orthostatic hypotension” may not capture patient with orthostatic syncope, because the hypotension occurs so quickly after standing up. Of note, patients may still have orthostatic tachycardia or intolerance with neurally mediated syncope. 

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Antibiotics in Sepsis

• Currently international guidelines for the management of sepsis and septic shock recommend antibiotic administration within 1 hour of recognition.
• With the persistent problem of ED boarding, many patients with sepsis and septic shock remain in the ED long after the initial dose of broad-spectrum antibiotics.
• A recent single center, retrospective cohort study demonstrated that 1 out of 3 patients with sepsis or septic shock experienced major delays in the time to the second dose of antibiotics.  In fact, over 70% of patients who were given an initial antibiotic with a 6-hr recommended dosing interval experienced major delays.
• Inpatient boarding in the ED was found to be an independent risk factor for major delays.
• Take Home Point: Don't forget to write for additional doses of antibiotics in your boarding patients with sepsis.

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