UMEM Educational Pearls

The majority of prescriptions used for the treatment of nausea and vomiting in pregnancy (NVP) in the United States have been with medications not labeled for and not classified as safe in use during pregnancy by the Food and Drug Administration. Over the last decade, the extremely potent 5HT3 receptor antagonist, Ondansetron (Zofran) has been increasingly used for NVP. However, the FDA has cautioned against its use in pregnancy based on recent studies regarding the association between Zofran use in early pregnancy and congenital cardiac malformations and oral clefts (cleft lip and palate). In addition, Zofran poses maternal risk of arrhythmias from possible QT interval prolongation which can result in the potentially fatal arrhythmia (Torsades de pointes) and Serotonin syndrome. The American College of Obstetricians and Gynecologists (ACOG) has issued new guidelines for the diagnosis and management of NVP. A safe and effective category A drug is available in the U.S., Diclegis (doxylamine succinate and Vitamin B6, pyridoxine hydrochloride) which has been studied in hundreds of thousands of pregnant women. Unisom SleepTabs (Sanofi Aventis; oral vitamin B6 and doxylamine), which are available OTC in the U.S., have been studied in more than 6000 patients and control participants, with no evidence of teratogenicity. In randomized trials, this combination has been associated with a 70% reduction in nausea and vomiting. ACOG therefore recommends this combination as first-line therapy for NVP. Following treatment failure with dietary modifications and alternative therapy remedies such as ginger capsules (250 mg qid) and acupuncture, pharmacologic therapies should include: 1. Vitamin B6 (pyridoxine), 10 to 25 mg every 8 hours, and doxylamine, 25 mg at bedtime and 12.5 mg each in the morning and afternoon. 2. If parental antiemetics are required, phenothiazides such as prochlorperazine or promethazine or Ondansetron in refractory cases. 3. Prokinetic agent Metoclopramide (Reglan; tablets, Alaven; injection, Baxter) is a dopamine antagonist. The FDA has issued a black-box warning concerning the use of Reglan in general. Because the risk for exrapyramidal complications, tardive dyskinesia increases with the duration of treatment and the total cumulative dose, treatment duration should not exceed 12 weeks. 4. Intravenous fluid replacement with multivitamins, especially thiamine is indicated with use of dextrose containing solutions (to prevent Wernicke's encephalopathy) until ketosis resolves.

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If you are interested in learning about the current status of emergency medicine in a specific country, it can be difficult to find up-to-date information. One excellent resource for country specific details is the American College of Emergency Physicians’ (ACEP) International Ambassador Program.

 

This program has Emergency Medicine Ambassadors (U.S. emergency physicians), Liaisons (in-country emergency physicians) and Representatives (U.S. emergency physicians in training) for many countries around the world.  Additionally, there are country specific reports that give annually updated information about emergency medicine in each country.

 

Included on the website are links to send emails to the Ambassadors, Liaisons and Representatives in order to request more detailed information. 

 

To learn more, see: http://www.acep.org/IntlAmbassador/

Classically, aortic dissection presents as tearing or ripping chest pain that radiates to the back in a HYPERtensive patient.

However, type A aortic dissections can quickly become HYPOtensive due to any the primary cardiac complications from retrograde dissection into:

• The pericardium causing cardiac tamponade
• The aortic valve causing wide-open aortic insufficiency
• One of the coronary arteries (typically the RCA presenting as inferior STEMI)

Bedside echo can't rule out aortic dissection, but it can help rule in the diagnosis (figure 1) or complications (figure 2) at times.

Attachments

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1509301038_PSL_dissection_flap.jpg (67 Kb)

Question

26 year-old male presents with a swollen 4^th digit and pain during extension, what’s the diagnosis?

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Most common mass in popliteal fossa

Incidence 10 to 58%

Intra-articular pathology results in flow of synovial fluid from the joint into the bursa, forming a cyst

Association with concomitant intra-articular disorders 94%

Possible pathology - Meniscus, ligamentous, arthritis, other osteochondral defects

In children this is not a pathologic finding

Symptoms - Posterior knee bulging, posterior tightness/stiffness esp. with knee flexion

Ultrasound - 100% sensitive/specific

DDx: DVT

Tx: Refer for ultrasound guided aspiration, fenestration and steroid injection

http://www.caringmedical.com/wp-content/uploads/2013/11/Bakers-Cyst-treatment.jpg

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A thunderclap headache is defined as a very severe headache that reaches its maximum intensity within 1 minute.

One of the most common causes (and the one associated with this buzzword on board questions!) is subarachnoid hemorrhage, but what else can cause a it?

- Reversible cerebral vasoconstriction syndrome (RCVS): suggested by recurrent thunderclap headaches (2-10) over 1 to 2 weeks. Normal CT and LP, with vasoconstriction on angiography. Can lead to SAH, ICH or ischemic stroke.

- Cervical artery dissection

- Cerebral venous sinus thrombosis

- Spontaneous intracranial hypotension: characterized by orthostatic HAs and auditory muffling.

- Intracerebral hemorrhage

- “Primary”: a diagnosis of exclusion

Bottom line? All patients with thunderclap HA should have a stat head CT with no contrast, then have SAH excluded with an LP, CTA or MRI/MRA. Just because you excluded SAH in a patient with thunderclap headache does not mean you’re done with the emergency workup. 

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• Evaluating the systolic function of the RV is an important skill and there are described methods.
• One of the simplest method is using the tricuspid annular plane of systolic excursion (or T.A.P.S.E.)
• This is how far the tricuspid annulus travels from diastole to systole because the RV contracts in a longitudinal fashion from the base (diastole) to the apex (systole)
• A TAPSE of <17mm is consistent with abnormal function and >17mm is normal. An eyeball method of assessment can be done when grossly obvious or M-mode can be used when an accurate assessment is required.
• The clip below demonstrates the technique, which should always be performed from an apical four-chamber view.
• Want more info on the RV, then click here for a whole podcast on it.

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Question

 30 year-old male with abdominal pain and diffuse tenderness on exam. Ultrasound is shown, what's the diagnosis?

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Shoulder Dislocation Reduction

Do you have a chronic dislocated that frequents your ED? Are you interested in teaching them a way to relocate their shoulder without looking like Mel Gibson from Lethal Weapon, https://youtu.be/Igrdi_lhhW4, then the newly described GONAIS method might be what you are looking for.

This technique has the patient grab the top of a chair with the hand on the affected side, and then slowly equating, effectively bringing the hand and arm above their head. Once in the full squat position the patient can step backwards which should reduce the shoulder. If not they can use the opposite hand to apply pressure to push the humerus backward and reduce the location.

The full article can be found at http://bit.ly/1iZ8a9z

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Is there a set of criteria similar to the Ottawa Ankle or Knee Rule that can be applied to the wrist in children?
The Amsterdam Pediatric Wrist Rules are as follows:
-Swelling of distal radius
-Visible deformity
-Painful palpation of the distal radius
-Painful palpation at the anatomical snuff box
-Painful supination
A positive answer to any of these would indicate the need for an xray.

The study referenced attempted to validate these criteria. This criteria is inclusive of the distal radius in addition to the wrist. The sensitivity and specificity were 95.9% and 37.3%, respectively in children 3 years through 18 years. This model would have resulted in a 22% absolute reduction in xrays. In a validation study, 7/170 fractures (4.1%, 95% CI: 1.7- 8.3%) would have been missed using the decision model. The fractures that were missed were all in boys ages 10-15 and were all buckle fractures and one non displaced radial fracture.

Bottom line: This rule can serve as a guide for when to obtain an xray in the setting of trauma, but it is not perfect.

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Monosodium glutamate

• Rapid onset 30 min and lasts about 1 hour
• May accompanied with headache & chest pain.
• No associated GI sx.
• History of eating Chinese fodd. AKA "Chinese restaurant syndrome"

 

Metabisulfites (Na sulfite, Na/K bisfulfite, Na/K metabisulfite, etc.)

• Food preservatives found in dried fruit, wine, molasses, sauerkraut, etc.
• Bronchospasm – asthma like, headache, mild hypotension can occur
• Most significant reaction in people with asthma/allergies
• History of trying to eat "healthy"

 

Tyramine reaction

• Mostly among patients taking MAO inhibitors
• Source of tyramine (food): fermented, pickled product, avocado, chocolate, etc.

 

Niacin

• Burning warm sensation to body
• Often used for sexual enhancement, elevated cholesterol and beating drug urine screens

 

Trichloroethylene

• Occupational exposure – AKA “Degreaser’s flush”
• Facial flushing, head pressure, lacrimation & blurred vision may occur
• Require several weeks of exposure prior to symptoms

 

Scrombroids

• Occurs after a “fish meal” (e.g. dark meat fish - tuna)
• Associated with GI symptoms (nausea, vomiting, diarrhea)
• Histamine related reaction due to poor refrigeration after catching fish.

 

Hydroxocobalamin

• Antidote for CN poisoning
• Skin become red after administration due to its color (red)

Which infectious disease listed as Class A agents occur naturally, though sporadically within the U.S?

 

• Anthrax- primarily in the West and Southwest (including Texas)
• Plague- western United States
• Tularemia- in all states except Hawaii, but most common south central US
• Botulism- throughout the U.S. Most common type reported is infant botulism
• Dengue- primarily Puerto Rico. Within the continental US, a small outbreak was reported from south Texas.

 

Small pox no longer occurs naturally and other viral hemorrhagic fevers occur in tropical settings.

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SIMV (Synchronized intermittent mandatory ventilation)

• A common mode of ventilation that all pratitioners should be familiar with
• It provides a minimum number of fully assisted breaths synchronized with patient respiratory effort
• Patient or time triggered
• Flow limited
• Volume cycled
• Any additional breaths are unassisted and determined by patient effort
• SIMV=AC when heavily sedated
• The idea is exercise the patients lungs but this can lead to increased work of breathing and fatigue, and prolong extubation when used

Question

35 year-old female presents to the Emergency Room with cough and chest tightness. She was discharged from the hospital yesterday for an asthma exacerbation that was secondary to pneumonia. What's the diagnosis?

 

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In the evaluation of ED patients, it may be important to understand the effect on pupil size from the ophthalmic medications they use. Here is a summary chart of common eye drops and their effect on pupil size.

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Serotonin Syndrome - What is It?

• Potentially life-threatening condition associated with increased serotonergic activity in the CNS.
• Selective serotonin reuptake inhibitors (SSRIs) are the most commonly implicated class of medications.  However, other medications can also be involved.
• It is a clinical diagnosis!
• Classic triad: mental status change, autonomic hyperactivity, and neuromuscular abnormalities
  • Mental status change - anxiety, agitation, restlessness, disorientation
  • Autonomic hyperactivity - diaphoresis, tachycardia, hypertension, hyperthermia, nausea, vomiting, diarrhea
  • Neuromuscular abnormalities - tremor, muscle rigidity, myoclonus, hyperreflexia, clonus, Babinski sign (abnormal plantar reflex)
• Hunter Criteria is the most accurate diagnostic rule:
  • Serotonergic agent + one of the following:
    • Spontaneous clonus
    • Inducible clonus + agitation or diaphoresis
    • Ocular clonus + agitation or diaphoresis
    • Tremor + hyperreflexia
    • Hypertonia + temperature above 38C + ocular clonus or inducible clonus
• Majority of cases present within 24 hours, most within 6 hours, of a change in dose or initiation of a medication.

 

** Stay tuned for part 2 on what causes serotonin syndrome **

 

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Hyperoxia in the Critically Ill

• Oxygen is liberally administered to many critically ill patients, thereby exposing them to supranormal arterial oxygen levels.
• Hyperoxia results in the formation of reactive oxygen species, which adversely affect the pulmonary, vascular, cnetral nervous, and immune systems.
• Though the optimal P_aO₂ remains unknown, recent evidence indicates that hyperoxia is associated with increased mortality in post-cardiac arrest, CVA, acute coronary syndrome, and traumatic brain injury patients.
• Take Home Point: Carefully titrate oxygen to the lowest tolerable level to meet the patient's needs.

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Question

68 year-old man presents with a new-onset seizure. What's the diagnosis and what's in your differential diagnosis?

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A new prospective, randomized, double-blind trial compared subdissociative ketamine to morphine for acute pain in the ED.

What they did

• 45 patients received IV ketamine 0.3 mg/kg (mean baseline pain score 8.6)
• 45 patients received IV morphine 0.1 mg/kg (mean baseline pain score 8.5)
• Source of pain was abdominal for ~70% in each group
• Exclusion criteria was pretty standard

What they found

• Pain score at 30 minutes: 4.1 for ketamine vs. 3.9 for morphine (p = 0.97)
• No difference in the incidence of rescue fentanyl analgesia at 30 or 60 minutes
• No serious adverse events occurred in either group
• Patients in the ketamine group reported increased minor adverse effects at 15 minutes post-drug administration

1. In an effort to reduce opioid use in the ED, low-dose ketamine may be a reasonable alternative to opioids for acute analgesia.
2. State nursing regulations govern who can administer IV ketamine in the ED.
3. What to prescribe on discharge? Lead author Dr. Motov recommends a "pain syndrome targeted" approach with "patient-specific opioid and non-opioid analgesics."

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Injuries are a leading cause of morbidity and mortality globally

• Approximately 5.8 million deaths annually
• 90% occur in lower and middle income countries

 

Injuries are the leading cause of preventable death in travelers

• Cause 18%–24% of deaths among U.S. travelers
• From 2011-2013, an estimated 2,466 US citizens traveling in foreign countries died from non-natural causes, such as injuries and violence
  • Excluded the wars in Iraq and Afghanistan
• Main causes for non-natural deaths among Americans are:
  • Motor vehicle crashes (n= 621, 25%)- the single largest cause
  • Homicide (n=555, 23%),
  • Suicide (n=392, 16%),
  • Drowning (n=309, 13%)

 

Bottom Line: Stay safe while travelling.  The same safety habits used in the US, such as wearing your seatbelt or not drinking and driving, are important patterns while traveling.

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