UMEM Educational Pearls

A recent study highlighted the challenges we face managing ED patients on warfarin therapy. Some key observations about how we're doing: 

• Only 71% of patients on warfarin had an INR checked
• Nontherapeutic INRs were recorded for 49%; ED providers intervened to address these results in 21% of cases
• 71% of patients with a supratherapeutic INR received an intervention compared with 9% of patients with a subtherapeutic INR
• 30% of patients received or were prescribed potentially interacting medications
• Recommendations for specific anticoagulation follow-up were documented for only 19% of all patients

Literature continues to show warfarin is the most dangerous medication for our patients. Meticulous monitoring and follow up will help us potentially avoid serious interactions and adverse events.

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• Micturation syncope is a relatively rare phenomenon (2.4 to 8.4% of fainting episodes) which most commonly affects males, and can often be diagnosed by simply taking a thorough history.
• Straining to urinate triggers the vagus nerve which results in hypotension and bradycardia; in turn, cardiac output and brain perfusion is decreased, often resulting in diaphoresis, pallor, and weakness, followed by syncope or fainting. 
• This process is transient and vital signs as well as consciousness typically return to normal rapidly.
• When evaluating a patient for syncope, pay close attention for the presence of the following factors in order to make the diagnosis:

             -- occurs during or immediately following urination, often when bladder is full.

             -- occurs at night or after standing from the recumbent position of a deep sleep to urinate.

             -- risk factors: enlarged prostate, alpha blocker therapy, dehydration, alcohol, fatigue.

• Sometimes defecation, coughing, or severe vomiting can also result in syncope.

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Up until recently, a tight-fitting mask was one of the only ways to deliver non-invasive positive-pressure ventilation.

High-flow nasal cannulas (HFNC) have been adapted from use in neonates to adults to deliver continuous positive airway pressure (CPAP).

HFNC provides continuous, high-flow (up to 60 liters), and humidified-oxygen via nasal cannula providing positive pressure to the pharynx and hypopharynx. Patients tolerate it well and it is less claustrophobic than tight-fitting masks.

HFNC does not generate the same amount of pressure as CPAP so it may be best utilized as an intermediate step between low-flow oxygen (i.e., traditional nasal cannula) and non-invasive positive pressure ventilation with tight-fitting masks.

Check with your respiratory department if these devices are locally available.

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Minimizing interruptions in chest compressions during CPR is critically important. As an example of the adverse consequences of interruptions, consider the following finding from Edelson (Resuscitation 2010): for every 10 seconds of hands-off time during cardiac arrest, the patient's chances of successful return of spontaneous circulation decreases by 50% due to reductions in cerebral perfusion.

Next time you are involved in a code, keep this in mind, and do EVERYTHING POSSIBLE to minimize those interruptions in chest compressions.

 

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You just finished assessing a 6 month old in the Pediatric ED who can’t move his right leg.  You suspect child abuse.  You’re ready to order labs, a head CT, ophtho consult, skeletal survey and call Child Protective Services.   While your doing all of this, your medical student asks you, “What exactly are you looking for on the skeletal survey?”

A skeletal survey is mandatory for cases of suspected child abuse in children under the age of 2 years.  Approximately 60% of the fractures seen in abused children are younger than 18 months old.

When you are looking at a skeletal survey, carefully look for the following:

1. Multiple, healing fractures of various ages

2. Rib fractures, especially in the posterior ribs

3. Metaphyseal chip and buckle fractures

4. Spiral fractures in long bones (especially in children that can’t walk)

5. Skull fractures which are not simple and linear

6. Scapula fractures

More to come about child abuse…. 

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A recent article estimated 100,000 emergency hospitalizations for adverse drug events in U.S. adults 65 years of age or older each year. Nearly half of these hospitalizations were among adults ≥80 years old and two-thirds were due to unintentional overdoses.

Four medications or medication classes were implicated alone or in combination in 67% of hospitalizations:

• Warfarin (33.3%)
• Insulins (13.9%)
• Oral antiplatelet agents (13.3%)
• Oral hypoglycemic agents (10.7%)

Opioids were #5. Digoxin was #7 and resulted in the highest percentage of hospitalizations per ED visit at 80%.

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High dose insulin is recommended in treatment of beta-blocker and calcium channel blocker overdose. In a recent observational case series of cardiogenic shock, high dose insulin was evaluated for efficacy and safety.

• Insulin doses were given at a maximum of 10 units/kg/hour.

• Seven patients who were on vasopressors when enrolled were tapered off when placed on high dose insulin.

• 11/12 patients lived and were discharged from the hospital.

• Adverse effects included hypoglycemia (19 events) and hypokalemia (8).

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• Seizures occur commonly and it is estimated that 1 of 26 people will develop epilepsy at some point in their life.
• A first seizure provoked by an acute brain insult is less likely to recur (3-10%) than a first-time unprovoked seizure (30-50% over the next 2 years).
• As an emergency provider managing an adult who presents with their first-ever seizure, there are four primary questions that require answering:

1. Was it in fact a true seizure? (often associated with tongue biting, urinary/bowel incontinence, preceding aura, post-ictal phase; examples of seizure mimics include syncope (i.e. cardiogenic, neurogenic, vasovagal), vertigo, myoclonic jerking, psychogenic convulsions, movement disorders.)
2. Does the patient have epilepsy? (defined a having at least 2 unprovoked epileptic seizures by any immediately identifiable cause.)
3. What type of epilepsy? (cryptogenic (i.e. of unknown etiology) or symptomatic (i.e. caused by prior central nervous system insult such as brain injury.)
4. What is the cause? (metabolic panels to assess for uremia, electrolyte and glucose abnormalities, and drug intoxications should be performed, as well brain imaging to determine the presence of focal intracranial lesions.)

• Many patients do not require anticonvulsant medication following a single, first time seizure; A general consensus is that such therapy should be strongly considered for initiation after a second episode of seizure activity. 

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Hypotension in the PAH Patient

• Hypotension in the critically ill patient with pulmonary arterial hypertension (PAH) must be rapidly treated to avoid cardiovascular collapse.
• Hypotension in the PAH patient is not always due to hypovolemia.  In fact, excessive volume loading may further decrease LV stroke volume.  Consider starting with a fluid bolus of 250 ml of an isotonic crystalloid solution and monitoring response.
• Patients with severe PAH may present to the ED with a continuous flow pump of a pulmonary vasodilator (epoprostenol, treprostinil).  These medications can also cause hypotension at excessive doses.  Consider decreasing the rate of the infusion by 25% to see if overdosing is the cause.

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Question

9 year-old boy with sudden onset of unilateral facial swelling. What’s the diagnosis?

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Right heart endocarditis is much more common in patients that are injection drug users. Fortunately for them, they have a lower mortality than patients with left heart endocarditis because they have a lower rate of developing heart failure. This is a reminder that the most common cause of death from endocarditis is heart failure.

The Weber classification system

A commonly used, simple, easily remembered system used to describe ankle fractures. The system focuses on the integrity of the syndesmosis.

http://www.accessemergencymedicine.com/loadBinary.aspx?fileName=simo_c017f013t.gif

  - TYPE A:  fibula fracture below the ankle joint/syndesmosis (which is intact). Deltoid ligament intact. Medial malleolus can be fractured. Usually treated with closed reduction.

http://www.gentili.net/image1.asp?ID=-241442344&imgid=AnkleWeberAAP600.jpg&Fx=Weber+A+Fracture

  - TYPE B:  is a transsyndesmotic fracture with usually partial rupture of the syndesmosis (though may be intact). No gross widening to the tib/fib articulation.. Deltoid ligament intact. Medial malleolus often fractured.  Variable stability. Any clinical or radiographic injury to the medial joint complex make this an unstable fracture

http://www.gentili.net/image.asp?ID=145&imgid=AnkleWeberBmortise600.jpg&Fx=Weber+B+Fracture

  - TYPE C:  Fibular fracture above the level of the syndesmosis with usually a total rupture of the syndesmosis (seen as widening of the distal tib/fin articulation), resulting in instability of the ankle mortise. Associated with medial malleolus fracture or deltoid ligament injury. Unstable.

http://www.gentili.net/image1.asp?ID=146&imgid=anklewebcapoblx2600.jpg&Fx=Weber+C+Fracture

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Attachments

1111251332_2009_Red_Book.doc (384 Kb)

• Studies have shown that the natural history of Bell's Palsy without treatment is such that 85% show signs of recovery within 3 weeks of symptom onset, and 71% experience complete recovery.
• Of the remaining individuals who do not completely recover, 13% experience persistent mild sequelae and 16% have residual weakness, synkinesis, and/or contracture.
• Those with incomplete lesions (i.e. incomplete paralysis) are more likely to return to normal function (94%), while only 60% of those with clinically complete lesions return to normal function.
• Herpes zoster is associated with more severe paresis and a worse prognosis.  When little to no recovery is seen within the first 21 days following symptom onset, the prognosis is less favorable.

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Determining the exact etiology of hypotension / shock can sometimes be difficult in the Emergency Department.

The Rapid Ultrasound for Shock / Hypotension (RUSH) exam is a sequential, 5 step-protocol (typically requiring less than 2 minutes) that can be used to determine the cause(s) of hypotension.

The mnemonic for the exam is “HI MAP”, and is easy to remember because a "HI MAP" is our goal with hypotensive patients.

H - Heart (parasternal and four-chamber views)
I  - Inferior Vena Cava (for volume responsiveness)
M - Morrison’s pouch (i.e., FAST exam) and views of thorax (looking for free fluid)
A - Aortic Aneurysm (ruptured abdominal aneurysm)
P - Pneumothorax (i.e., Tension PTX)

Refer to the link for a more detailed discussion and podcast from the creators of this exam: emcrit.org/rush-exam

Reasons for acutely elevated troponins
ACS
Acute heart failure
PE
Stroke
Aortic dissection
Tachyarrhythmias
Shock
Sepsis
Perimyocarditis
Endocarditis
Tako-tsubo cardiomyopathy
Cardiac contusion
Strenuous excercise
Sympathomimetic drugs
Chemotherapy

I guess that means that your history, physical, and clinical judgment still supersede the lab test.

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Low Back is one of the most common complaints that we see in the Emergency Department.  Our first priority is to rule out those causes that can lead to paralysis or death (i.e.: epidural abscess, pathological fracture, cauda equina syndrome, etc…).  However, most of the back pain that we will see is musculoskeletal in origin.

The American College of Physicians (ACP) and the American Pain Society (APS)  released  joint recommendations on the evaluation of treatment of individuals with back pain in 2007.

In summary their key recommendations were:

1. Routine imaging is not required. However, diagnostic imaging and testing should be obtained for patients with low back pain when severe or progressive  neurologic deficits are present or when serious underlying conditions are suspected.
2.  For patients with low back pain, clinicians should consider the use of medications with proven benefits in conjunction with back care information and self-care. For most patients, first-line medication options are acetaminophen or nonsteroidal anti-inflammatory drugs.
3. Medications that have good evidence of short-term effectiveness for low back pain are NSAIDs, acetaminophen, skeletal muscle relaxants (for acute low back pain), and tricyclic antidepressants (for chronic low back pain).

Links to the Clinical Guidelines are listed below:

• Evaluation and Treatment
• Nonpharmacologic Therapies for Acute and Chronic Low Back Pain
• Medications for Acute and Chronic Low Back Pain

Child Passenger Safety.

Perhaps one of the greatest contributions emergency physicians can provide to society comes in the  form of anticipatory guidance. It is important to take the opportunity during the ED encounter to provide information to parents to prevent future injuries. Child passenger safety is one clear example. With over 330,000 pediatric visits to EDs  across the US annually attributed to motor vehicle collisions, the need to provide clear recommendations to parents on how to restrain their children in their vehicle is paramount. Despite a recent survey of over 1000 EPs in which 85% of respondents indicated child passenger safety should routinely be a part of pediatric MVC discharge instructions, only 36% of EPs knew the latest guidelines on child passenger safety.   The American Academy of Pediatrics provides such guidelines. These recommendations were recently adjusted in 2011.

(1) Infants up to 2 years must be in REAR-facing car seats
(2) Children through 4 years in forward-facing car safety seats
(3) Belt-positioning booster seat for children through at least 8 years old
(4) Lap-and-shoulder seat belts for those who have outgrown booster seats. How does one know when the child has outgrown the booster seat?
     a. Can the child sit with his/her knees bent at the edge of the seat?
     b. Does the shoulder belt lie across the middle of the chest/shoulder?
     c. Does the lap belt lie across the upper thighs and not the abdomen?
(5) Children younger than 13 should sit in the rear seats

Special Thanks to JV Nable, MD, EMT-P for writing this pearl.

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TEN is a rare, life-threatening dermatologic emergency characterized initially by erythema and tenderness. It is followed by a severe exfoliation that resembles a severe burn patient. Classically occurs within days of the exposure of the drug. Nikolsky's sign may be present - not pathognomonic.

The following is a short list of medications that can cause this lethal reaction:

allopurinol, bactrim, nitrofurantoin, NSAIDs, penicillin, phenytoin, lamotrigine, sulfasalazine

Treatment: transfer to a burn center may be needed, steroids are not generally recommended however immunomodulators are beginning to show promise - IVIG, cyclosporine and cyclophosphamide

See pic that is attached for example of the sloughing

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1111172057_TENPic.jpg (95 Kb)

• Myasthenia Graves (MG) is an autoimmune disorder wherein antibodies attack acetylcholine nicotinic postsynaptic receptors at the myoneural junction, resulting in muscle fatigue (commonly bulbar) that worsens with use and improves with rest.  MG flares are most commonly due to infection or inadequate treatment with cholinesterase inhibitors.

• The Tensilon (edrophonium) challenge test can be used to help distinguish an MG crisis from a cholingergic crisis.  Once the airway and ventilation are secure, escalating doses of edrophonium (i.e. 1 mg, then 3 mg, then 5 mg, up to a maximum of 10 mg total) can be administered with the goal of relieving the muscle weakness.  If a true MG crisis is present, patients usually respond with dramatic improvement within 1 minute.  Patients having a cholinergic crisis, on the other hand, typically respond with increased salivation, bronchopulmonary secretions, diaphoresis, and gastric motility.  

• Monitor closely as edrophonium can cause significant bradycardia, heart block, and asystole (only 0.16% risk by reports, but have atropine nearby). 

• Once the edrophonium wears off, patients having an MG crisis may develop increased secretions and respiratory distress as their muscle weakness returns, so manage expectantly and with caution.  

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