Sunset Eye Sign

• The "sunset eye sign" can be seen in patients with increased intracranial pressure related to obstructive hydrocephalus or shunt malfunction.
• It describes an up-gaze paresis caused by compression of the dorsal midbrain.
• The lower portion of the pupil may be covered by the lower eyelid, appearing like a setting sun.

• The RUSH exam is a rapid way to identify the cause of shock using ultrasound. What's the RUSH exam? Click here
• The RUSH exam does not include an assessment of volume responsiveness (VR), but a new article by Blaivas, Aguiar, and Blanco suggests that it should be.
• VR has classically been assessed by determining the stroke volume before and after a passive leg raise or a fluid bolus. Click here for a video on how to calculate the stroke volume (skip to 21:30 in the video)
• The authors claim that VR can further be simplified by not measuring the left ventricular outflow tract (LVOT) and only comparing changes in the velocity-time integral (VTI). The assumption is that the LVOT is constant and doesn't change in most circumstances; a change of VTI that is greater than 15% suggests that the patient is VR
• Further validation is required to determine the degree of benefit to adding VTI to the RUSH exam, however measuring VTI is a skill that can be done with relatively little training and is clinically helpful.

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A new guideline for convulsive status epilepticus in adults AND children was recently published. [1] An insightful commentary was published alongside it (both are open access). [2] The proposed algorithm is below. Here are a few additional points to note:

• The guideline applies to convulsive status epilepticus.
• A new level of evidence rating of "U" is utilized. It means "data inadequate or insufficient; give current knowledge, treatment is unproven."
• It addresses 5 specific questions:
  • Which anticonvulsants are efficacious as initial and subsequent therapy?
  • What adverse events are associated with anticonvulsant therapy?
  • Which is the most effective benzodiazepine?
  • Is IV fosphenytoin more effective than IV phenytoin?
  • When does anticonvulsant efficacy drop significantly?
• IM midazolam is incorporated as one of the recommended 1st choices of treatment.
• One of the second phase therapy recommendations is levetiracetam 60 mg/kg! It is a level U recommendation. Be prepared for neurology to request this dose. There is no data in adults to support this high of a dose.

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Pure opioid agonists such as Morphine, Hydromorphone, and Fentanyl stimulate opioid receptors and are the most potent analgesics. Fentanyl and fentanyl analogues are up to 100 times more powerful than morphine and 30-50 times more powerful than heroin.

• Fentanyl abuse is causing significant problems worldwide. In the U.S., age-adjusted rate of death involving Fentanyl has increased 80% in 2014.
• Sources include production in illicit clandestine labs or diversion from legitimate pharmaceutical sales.
• 12 different analogues of Fentanyl have been identified in the U.S. drug traffic market.
• Commonly laced in heroin or cocaine or sold as fake Oxycodone or OxyContin tablets.

W-18 is a highly potent opioid agonist with a distinctive chemical structure which is not closely related to older established families of opioid drugs. While Fentanyl is approximately 100 times more powerful than Morphine, W-18 is about 100 times more powerful than Fentanyl.

• First discovered at the University of Alberta in 1982 in hopes of producing a non-addictive analgesic, 32 compound series named from W-1 to W-32, with W-18 being the most potent.
• Recently emerged on the streets of Canada when police in Calgary confiscated 110 green pills being sold as Fentanyl, known on the streets as "shady eighties" or "green beans pills" but chemical analysis revealed some pills containing W-18 instead.
• W-18 has never been used clinically as drug companies did not pick the patent, which lapsed by 1992 so little clinical experience.
• The effects of naloxone to reverse this synthetic opioid are unknown and higher doses are expected to to be required.
• Illicit drug manufacturers research pharmacological history in search of the more powerful, exotic, and new opioids to circumvent current legal regulations.

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While the flu season this year has been mild, it is still important to recognize which patients are at high risk for flu-related complications:

• Children < 5 years old
  • Especially children < 2 years old
• Adults > 65 years old
• Pregnant women
  • Including women up to 2 weeks post-partum
• Residents of long-term care facilities, such as nursing homes
• American Indians and Alaskan Natives
• Patients with certain medical conditions, including:
  • Respiratory diseases, such as asthma and COPD
  • Neurological and neurodevelopmental conditions
  • Heart disease, including CHF and CAD
  • Blood disorders (e.g. sickle cell disease)
  • Endocrine and metabolic disorders (e.g. diabetes)
  • Kidney or liver diseases
  • People <19 years old on long-term aspirin therapy
  • Morbid obesity (BMI > 40)
  • Immunocompromised, (e.g. chronic steroids, transplant patients, AIDS patients, chronic steroid use)

During the influenza season, when admitting a patient who 1) has respiratory symptoms and 2) is at high risk for influenza complications, consider testing them for influenza.

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• A recent observational study was published looking at the ICU incidence and outcome of ARDS
• This international prospective cohort study looked at 459 ICUs and over 29,000 patients
• Incidence: 10.4% met ARDS criteria
• Severe ARDS occurred in 23.4%
• Clinical recognition of mild ARDS was only 51%
• Less than 2/3rds of patients with ARDS received a TV of 8 mL/kg or less
• Prone positioning was used in 16% of patients with severe ARDS
• Recognition of ARDS was associated with higher PEEP, greater use of neuromuscular blockers, and prone positioning
• Mortality ranged from 35% to 46%
• Pneumonia was the biggest risk factor for ARDS

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Question

19 year-old male complaining of left arm pain one week after injecting anabolic steroids into his shoulder. What's the diagnosis?

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Achilles tendon rupture

More common in

men, ages 30 - 40yo, s/p steroid injections, fluoroquinolone use, and episodic athletes "weekend warriors

Mechanism: usually during an athletic endeavor, sudden forced planar flexion or violent dorsiflexion of a plantar flexed foot

Location: Usually occurs 4 to 6 cm ABOVE the Achilles calcaneal insertion (hypovascular region)

Patient will report a sudden pop, gunshot like sound

History: Will report heel and calf pain and weakness/inability to walk

Physical examination: Palpable gap, weakness with plantar flexion, + Thompsons test

https://www.netterimages.com/images/vpv/000/000/007/7714-0550x0475.jpg

Consult orthopedics and splint in resting equinus

http://img.medscape.com/fullsize/migrated/408/535/mos0216.01.fig5b.jpg

Perianal Group A Strep is an infectious dermatitis seen in the perianal region that is caused by Group A beta-hemolytic Strep. Children will have a characteristic rash with a sharply-demarcated area of redness, swelling, and irritation around the perianal region. There may be associated swelling and irritation of the vulva and vagina (in girls) and penis in boys. Patients can have bleeding or itching during bowel movements.

The age range is often <10 years of age. There is often an absence of fever or other systemic symptoms.The diagnosis can be confirmed by obtaining a Rapid Strep swab from the area of interest. You can also collect a bacterial culture of the area.

Treatment requires a 14 day course of penicillin. Amoxicillin (40 mg/kg/day divided TID) and clarithromycin are alternative treatments. The additional of topical bactroban (mupirocin) can be effective, but it should not be used as monotherapy. Re-occurrence is common, so close follow-up is key.

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Sepsis-3

• After nearly 2 decades, the definitions for sepsis and septic shock have been updated.
• Key findings from the Task Force convened by SCCM and ESICM include:
  • Sepsis
    • Definition: life-threatening organ dysfunction due to a dysregulated host response to infection
    • ICU patients: organ dysfunction is defined as an increase of 2 points or more in the Sequential Organ Failure Assessment (SOFA) score
    • ED patients: 2 or more of the following new qSOFA (quickSOFA) score may identify patients with increased mortality
      • SBP less than or equal to 100 mm Hg
      • RR greater than or equal to 22
      • Altered mental status
  • Septic Shock
    • Definition: a subset of patients with sepsis and profound circulatory, cellular, and metabolic abnormalities
    • Clinical Criteria:
      • Persistent hypotension requiring vasopressors to maintain MAP greater than or equal to 65 mm Hg despite adequate volume resuscitation
      • Lactate greater than or equal to 2 mmol/L
  • The term "severe sepsis" is no longer used

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Colchicine is an alkaloid compound found in Colchicum autumnale that is often mistaken by foragers as wild garlic (Allium ursinum). Unintentional ingestion wild garlic or therapeutic misadventures among elderly population with history of gout often result in unintentional toxicity.

It is a potent inhibitor of microtubule formation and function involved in cell division and intracellular transport mechanism. Thus toxicity is related to diffuse cellular dysfunction of all major organs and results in significant morbidity and mortality.

Colchicine toxicity occurs in three phases:

Management

• Primarily supportive care as no antidote is available.
• ICU admission due to risk of sudden cardiac death in symptomatic patients.
• Patients who does not manifest GI symptoms within 8 -12 hr are unlikely to be significantly poisoned.

There is not much data published on susceptabilities of urinary pathogens in infants. What resistance patterns are seen in infants < 2 months in gram negative uropathogens?

A retrospective study of previously healthy infants diagnosed with urinary tract infections in Jerusalem over a 6 year period examined this question. The standard treatment at this hospital included ampicillin and gentamycin for less than 1 month olds and ampicillin or cefuroxime for 1-2 month olds.

306 UTIs were diagnosed

74% were resistant to ampicillin

22% were resistant to cefazolin and augmentin

8% were resistant to cefuroxime

7% were resistant to gentamycin

Of the organisms cultured, 76% were E. coli and 14% were Klebsiella.

Bottom line: Know your local resistance patterns.

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What are the criteria for dengue hemorrhagic fever?

• Fever lasting 2-7 days
  • May be biphasic

• Hemorrhagic tendencies
  • Positive tourniquet (aka Rumpel-Leede) test
  • Petechiae, ecchymosis or purpura
  • GI bleeding

• Thrombocytopenia (<100,000/mm³)

• Evidence of plasma leakage
  • Increase in hematocrit >20% above age/sex normal
  • Decrease in hematocrit >20% after volume replacement
  • Signs of plasma leakage
    • e.g. pleural effusions, ascites, hypoproteinemia

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Spondylolysis

Prevalence 3-6% in the general population (Higher in athletes)

Location: L4 (5-15% of cases) & L5 (85-95% of cases)

Population: More likely in the skeletally immature athlete due to the vulnerability of the immature pars interarticularis to repeated stress

Symptoms: Lumbar pain worse with extension

Higher risk sports: Gymnastics, diving, weightlifting, wrestling

Treatment: Bracing and activity modification, physical therapy

- Good results in 80% with conservative management allowing return to play.

- Those who fail benefit from iliac crest bone grafting and posterolateral fusion.

-Return to play is controversial in this group

Please review th images below for anaomy and imaging appearence

http://orthoinfo.aaos.org/figures/A00053F01.jpg

http://www.sonsa.org/images/spondylolysis.jpg

http://www.physio-pedia.com/images/2/22/Spondylolysis_x_ray_.docx.jpg

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Borrella mayonii a new species

There is a new bacteria that is causing Lyme disease. Borrella burgdorferi is the typical bacteria associated with lyme disease, but now several cases of Borrelia mayonii have been isolated from patients and ticks that live in Minnesota, Wisconsin and North Dakota. What is unique about this new species is that it is associated with nausea, vomiting, diffuse macular rashes, and neuro symptoms [e.g.: confusion, visual disturbance, and somnolence) along with the typical lyme disease symptoms of arthralgias and headaches.

Current lyme tests should detect this new species and treatment is the same as Borrella burgdorferi. The take home pearl is that we may see patients with "atypical" lyme disease symptoms so this should be on our differential for patients presenting with rashes, nausea, vomiting and neurologic complaints.

In September 2013, an international group representing major societies in toxicology and nutrition support began collaborating on a comprehensive review of lipid use in poisoning. Six total papers will be published, with the most recent two made available online this week. Here are the available (and forthcoming) papers:

1. Gosselin S, et al. Methodology for AACT evidence-based recommendations on the use of intravenous lipid emulsion therapy in poisoning. Clin Toxicol 2015;53(6):557-64. [PMID 26059735]

2. Grunbaum AM, et al. Review of the effect of intravenous lipid emulsion on laboratory analyses. Clin Toxicol 2016:54(2):92-102. [PMID 26623668]

3. Levine M, et al. Systematic review of the effect of intravenous lipid emulsion therapy for non-local anesthetics toxicity. Clin Toxicol. 2016;54(3):194-221. [PMID 26852931]

4. Hoegberg LC, et al. Systematic review of the effect of intravenous lipid emulsion therapy for local anesthetic toxicity. Clin Toxicol. 2016;54(3):167-93. [PMID 26853119]

5. Hayes BD, et al. Systematic Review of Clinical Adverse Events Reported After Acute Intravenous Lipid Emulsion Administration. Clin Toxicol. 2016 Apr 1. [Epub ahead of print] [PMID 27035513]

6. The final paper, which is in process, is the consensus recommendations from the workgroup based on the 4 systematic reviews.

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• Cerebral venous thrombosis (CVT) is a rare but potentially life-threatening disease.
• Mortality in CVT is largely attributed to herniation.
• The diagnosis of CVT is made on the basis of clinical presentation and imaging studies.
• When you are concerned about CVT in a patient, which neuroimaging modality should you obtain?  CT or MRI?
• Non-contrast CT
  • Often the first neuroimaging obtained as it can evaluate for other processes such as cerebral infarct, intracranial hemorrhage, and cerebral edema.
  • Dense delta sign, dense clot sign and cord sign all refer to hyperattenuation of the clot. 
  • However, these findings are only seen in 20-25% of cases and disappear within 1-2 weeks.
• MRI
  • Clot appears hyperintense in the subacute phase.
  • In the acute phase, clot can mimic normal venous flow signal and result in potential diagnostic error.
• CT venography
  • Detailed depiction of cerebral venous system.
  • Timing of contrast bolus affect quality of evaluation.
  • Reconstruction may be difficult to subtract all of the adjacent bone.
• MR venography (MRV)
  • Unenhanced time-of-flight (TOF) MR venography has excellent sensitivity to slow flow.  It is useful in detection of large occlusions (e.g. jugular venous thrombosis), but susceptible to flow artifacts.
  • Contrast enhanced MR venography improves visualization of small vessels, thus preferred to TOF MR venography.

Bottom Line:  CT venography is good for diagnosing CVT, but MRI/MRV is superior for detection of isolated cortical venous thromboses and assessing parenchymal damage.

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• Transthoracic echocardiography (TTE) is an essential tool during cardiac arrest because it identifies potentially reversible causes (e.g., tamponade, massive PE, etc.).
• One of the limitations of TTE is that it is sometimes difficult to assess the heart in less than ten seconds (i.e., during a pulse check) and good views of the heart sometimes hard to obtain. Transesophageal echocardiography (TEE) offers the potential to overcome these obstacles.
• TEE not only allows continuous visualization and better imaging of the heart during arrest, but it also allows the assessment of compression depth, and whether the heart is being correctly compressed during CPR.
• Here is what a TEE probe looks like, here is an example of a TEE during arrest, and here is a podcast by @ultrasoundpodcast on the literature for using TEE during cardiac arrest.

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An interesting new study was published looking at in-hospital mortality in TBI patients who received succinylcholine or rocuronium for RSI in the ED.

What They Did

• Retrospective cohort study
• 233 patients (149 received succinylcholine, 84 received rocuronium)
• Groups were well matched overall (roc group was older, more hypotension in sux group)
• Within the two groups, patients were separated based on head Abbreviated Injury Score (scores of 4 or 5 were considered severe)
• The authors controlled for a lot of confounding factors

What They Found

• Overall, mortality was the same in each group (23%)
  • Mortality within the roc group was the same irrespective of head AIS
  • Mortality within the sux group was significantly higher in the subset of patients with higher head AIS (OR 4.1, 95% CI 1.18-14.12, p = 0.026)

Application to Clinical Practice

• Succonylcholine may increase mortality in severe TBI patients undergoing RSI in the ED compared to rocuronium
• The confidence interval was wide and these findings need to be confirmed in a prospective study
• Though the patients were well matched and the authors controlled for many variables, it still is difficult to pinpoint one intervention as the cause for mortality in critically ill patients (eg, etomidate + sepsis)
• With proper rocuronium dosing, intubating conditions are similar to succinylcholine. So if there is a potential for increased mortality in severe TBI patients with sux, rocuronium seems to provide a safer alternative.

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