Question

31 year-old male with recently diagnosed hypertension presents with rapid lip swelling. He started taking an unknown medication for his hypertension last week. Further history reveals that he has had prior, although milder, episodes previously. Name two medications that may help treat him.

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• Type 1: Ischemic myocardial necrosis secondary to plaque rupture (ACS)
• Type 2: Ischemic myocardial necrosis not secondary to ACS, but rather supply/demand mismatch, vasospasm, emboli, anemia, hypoperfusion, and/or arrhythmia
• Type 3: Sudden cardiac death
• Type 4a: PCI related
• Type 4b: Stent thrombosis
• Type 5: CABG related 

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Metacarpal Neck Fractures (i.e.: Boxer’s Fracture if 5^th Metacarpal)

Depending on the MCP joint involved a certain amount of angulation is permissible before it adversely affects normal function.

• 2^nd and 3^rd Metacarpal fractures < 10۫ angulation ideally these should be perfectly aligned.
• 4^th Metacarpal fracture <20۫ angulation allowed
• 5^th Metacarpal fracture <30۫ angulation.
  • Studies have shown that even 30۫ angulation will decrease normal function by 20%.  
  • Normal excursion of the 5^th MCP is 15۫ to 25۫.
• No amount of rotation deformity should be allowed.

Wishing everybody a Happy and Healthy New Year.

Despite a paucity of data, pain management clinics are administering topical gel mixtures that have included ketamine, tricyclics, calcium channel blockers and baclofen. Internet blogs have already identified this gel mixture as a way to "get high".  This is one of those google searches you have to do on your own.

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  1: Lynch ME, Clark AJ, Sawynok J, Sullivan MJ. Topical 2% amitriptyline and 1%  ketamine in neuropathic pain syndromes: a randomized, double-blind,  placebo-controlled trial. Anesthesiology. 2005 Jul;103(1):140-6.     2: Lynch ME, Clark AJ, Sawynok J. A pilot study examining topical amitriptyline, ketamine, and a combination of both in the treatment of neuropathic pain. Clin J Pain. 2003 Sep-Oct;19(5):323-8.    3: Uzaraga I, Gerbis B, Holwerda E, Gillis D, Wai E. Topical amitriptyline,  ketamine, and lidocaine in neuropathic pain caused by radiation skin reaction: a pilot study. Support Care Cancer. 2012 Jul;20(7):1515-24.   

University of Maryland Section for Global Emergency Health

Author: Emilie J.B. Calvello, MD, MPH

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Attachments

• 1212252349_Malaria_Pearl_Visual_EJBC_copy.pdf (1,967 Kb)

VV-ECMO for Refractory Hypoxemia

• In the absence of significant cardiac disease, patients with refractory hypoxic respiratory failure should be considered for venovenous extracorporeal membrane oxygenation (VV-ECMO).
• Though indications vary slightly among organizations, the Extracorporeal Life Support Organization states that ECMO is indicated when the P_aO₂/F_iO₂ is < 80 mm Hg on F_iO₂ > 90% or safe plateau pressures (< 30 cm H₂O) cannot be maintained.
• A few pearls when initiating VV-ECMO:
  • Fluids are often needed in the first few hours after initiation of ECMO
  • Reduce tidal volumes to maintain plateau pressures < 25 cm H₂O
  • Decrease F_iO₂ to maintain oxygen saturations > 88%
  • Use a hemoglobin threshold of 7-8 g/dL for blood transfusion

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Question

52 year-old male with diabetes complains of severe left foot pain for one month and now inability to ambulate. Vital signs are normal and X-rays are shown below. What's the diagnosis and why should you get a biopsy early?  

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• ST-elevation may represent STEMI or other alternative diagnoses (e.g., aortic dissection)
• Computed tomographic (CT) scanning may help in identifying these alternative diagnoses
• ACTIVATE-SF Registry consists of patients w/a Dx of STEMI admitted to the ED 
• 410 patients w/a suspected diagnosis of STEMI, 45 (11%) underwent CT scanning before primary PCI; 2 (4%) of these CT scans changed clinical management by identifying a stroke
• Those who underwent CT scanning had far longer door-to-balloon times (median 166 vs 75 minutes, p <0.001) and higher in-hospital mortality (20% vs 7.8%, p=0.006)
• CT scanning before PCI rarely changed management and was associated w/significant delays in door-to-balloon times

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NSAIDs are commonly used by professional and recreational athletes to both reduce existing and/or prevent anticipated exercise induced musculoskeletal pain

NSAIDs have potential hazardous effects on the gastrointestinal (GI) mucosa  during strenuous physical exercise

Potential effects include mucosal ulceration, bleeding, perforation. and short-term loss of gut barrier function in otherwise healthy individuals

Intense exercise by itself has previously been shown to induce small intestine injury

Human intestinal fatty acid binding protein (1-FABP) is a protein found in mature small bowel enterocytes which diffuses into the circulation upon injury

Ibuprofen and endurance exercise (cycling) independently result in increased 1-FABP levels

When occurring together, ibuprofen ingestion with subsequent exercise causes significantly increased small bowel injury and intestinal permeability

Small bowel injury was found to  be reversible in 2 hours

Taking empiric NSAIDs before endurance exercise may be an unhealthy practice and should be discouraged in the absence of a clear medical indication

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Parents bring in their child who placed a bead, seed, or other object up her nose.  What do you do?  Who should you call?

Research suggests that a decades-old home remedy (of sorts) known as the “mother’s kiss” may do the trick for children 1-8 years of age. It’s also much less invasive or frightening than some of the tools and techniques used in emergency departments with a success rate approaching 60%

What Is the “Mother’s Kiss”?

First described in 1965, here’s how the mother’s kiss technique works:

• The parent or caretaker places their mouth over their child’s mouth while holding the unaffected nostril closed with one finger.
• The parent or caretaker blows into the child’s mouth.
• The forceful breath may force the object out (warning: may want to wear protective covering as other things have been known to fly out as well!)

Myth: The ornamental red plant - poinsettia - gained a reputation as a poisonous plant from a case report. In 1919, a 2-year-old child reportedly died from an ingestion and later an 8-month-old developed mucosal burns.  These anectdotal case reports perpetuated the myth that poinsettia plants are poisonous. In the modern literature there is one single case of anaphylaxis(1) due to poinsettia ingestion/exposure, an allergic dermatitis(2) and one case of dermatitis(4). 

Krenzelok et al.(3) showed there were 22,793 cases of poinsettia exposure and there were no fatalities reported to poison centers. 96.1% were kept at home without sequelae.

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  1: Kimata H. Anaphylaxis by poinsettia in infants with atopic eczema. Allergy.  2007 Jan;62(1):91-2.     2: Bala TM, Panda M. No poinsettia this Christmas. South Med J. 2006  Jul;99(7):772-3.    3: Krenzelok EP, Jacobsen TD, Aronis JM. Poinsettia exposures have good  outcomes...just as we thought. Am J Emerg Med. 1996 Nov;14(7):671-4.     4: Edwards N. Local toxicity from a poinsettia plant: a case report. J Pediatr.1983 Mar;102(3):404-5.  

·      A parasitic disease transmitted by the bite of the 'Glossina' insect  (tsetse fly.)

·      The disease is most prevalent in rural areas of Africa. Untreated, it is usually fatal. Infection with the genus Trypanosoma brucei gambiense may lead to chronic asymptomatic illness.

·      Travelers to endemic areas in Africa are risk becoming infected.

·      Symptoms resemble a viral illness; headaches, fever, weakness, pain in the joints, and stiffness. The parasite is able to crosses the blood-brain barrier and causes neurological symptoms, mainly psychiatric disorders, seizures, coma and ultimately death.

·      Diagnosis is by serological tests (Card Agglutination Trypanosomiasis Test or CATT). Confirmation of infection requires the performance of parasitological tests to demonstrate the presence of trypanosomes in the patient.

·      Treatment: four drugs are registered for the treatment of HAT: pentamidine, suramin, melarsoprol and eflornithine.

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Management of patients with severe traumatic brain injury (TBI) typically involves the use of invasive intra-parenchymal pressure monitors. Although use of these monitors is recommended by TBI management guidelines, good quality evidence of benefit is lacking.

A recently published study evaluated the outcomes of TBI patients using a management protocol incorporating either an intracranial pressure (ICP) monitor compared to use of the clinical exam PLUS serial neuroimaging; a total of 324 patients were prospectively randomized into either group.

The primary study outcome was a composite of survival, impaired consciousness, and functional status at both three and six months.

The results of the study did not show a significant difference in the:

• Primary outcome  
• Median length of ICU stay
• Distribution of serious adverse events

Bottom line: This study suggests that clinical exam PLUS serial neuroimaging may perform as well as invasive intra-parenchymal monitors for guiding therapy in TBI patients.

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Question

50 year-old man with presents with acute-onset sharp left-sided chest pain and dyspnea. What's the diagnosis and the name of the abnormality on chest x-ray?

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• PAH can be classified as primary (PPH) or secondary pulmonary hypertension (SPH)
• Epoprostenol a prostacyclin analog was the first primary drug for patients w/PAH
• Recent clinical trials describe combination therapy as superior in efficacy to traditional monotherapy
• Varied etiologies of PAH hampers the performance of RCTs for each combination therapy
• PAH is associated w/diminished endothelium factor & nitric oxide, increased phosphodiesterase enzyme leading to the development of the ET-1 receptor antagonist (ERA) bosentan and the PDE- V inhibitor sildenafil
• RCTs are currently investigating the efficacy of three news agents in tx of PAH: imatinib, riociguat, and selexipag 

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Epistaxis can be a difficult thing to control in the ED, but there are several techniques you can learn that will make your life easier.

The majority of epistaxis cases are from kiesselbach's plexus therefore you can control it with:

Direct Pressure: Can be held with two fingers pinching the nares, or you can tape 4 tongue blades together and make your own "clothes pin" that can then be used to pinch the nares.

Vasoconstrictor and Anesthesia: A 1:1 mixture of topical lidocaine 4% and oxymetazoline can often be mixed together in the same oxymetazoline spray container enabling you to just spray it into the nares. This will often slow or stop the bleeding and provides anesthesia in case you need to cauterize the bleeding site.  Some IV/IM narcotic pain medication will also help increase patient cooperation.

Visualize the bleeding site: Use a HEAD LAMP with an appropriate sized nasal speculum. You may look like Marcus Welby, MD but nothing works as well to see into the nose.

Cauterization It is best to cauterize circumferential around the bleeding site prior to directly cauterizing the actual site. Be careful with electrical cautery so has not to perforate the septum.

Nasal Packing: Instead of using surgilube to lubricate the packing; use Muprion, Bactroban or Bacitracin ointment to lubricate the packing. This will reduce the chance of Toxic Shock Syndrome.

The more well known causes of toxin-induced hyperthermia include sympathomimetics and anticholinergics. In addition, neuroleptic malignant syndrome, serotonin syndrome, and malignant hyperthermia are high on the differential.

Several other xenobiotics can cause hyperthermia in overdose as well:

• Salicylates and dinitrophenol cause hyperthermia by uncoupling oxidative phosphorylation.
• Thyroid medications cause hyperthermia via thyroid hormone's thermogenic effect and psychomotor agitation. Hyperthermia can be extreme (>106°F, >41°C).
• Caffeine/theophylline, isoniazid, and strychnine cause hyperthermia through refractory seizures and muscle contraction. Highest temp recorded with strychnine is (109.4°F, 43°C).

In general, benzodiazepines should be considered first-line therapy, followed by barbiturates, propofol, or other sedative hypnotics. Phenytoin rarely has a role in the management of toxin-induced seizures. Extrenal cooling measures are also warranted. Specifically for isoniazid, pyridoxine should be administered immediately with a benzodiazepine.

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Background:

Dengue is the most rapidly expanding mosquito-borne virus with an increasing incidence and geographical area.  It is most commonly found in the tropics, but there are occasional outbreaks in other places, including Texas and Hawaii.

Clinical:

Three Phases:

1.  The febrile phase lasts 2-7 dyas and is similar to other viral syndromes, often with high fever and nausea/vomiting.  Petechiae may also be present which can be induced by the application of a tourniquet.

2. The critical phase occurs after defervescence and lasts only 24-48 hours. IT is marked by increased capillary permeability and can lead to severe pulmonary edema, shock, and multisystem organ failure.

3. The recovery phase is marked by hemodynamic improvement. Some patients have a rash described as "isles of white in a sea of red." 

Some patients will develop bradycardia. Most patients have a self-limited form of the illness that is not severe, and consists of symptoms seen in the febrile phase.  The patients that develop severe dengue can have markers in the febrile phase that are associated with organ dysfunction, GI bleeding, and increased capillary permeability. Other concerning symptoms early are abdominal tenderness and persistent vomiting.

Treatment:

Treatment is supportive, mostly consisting of IV fluids, which is very effective when started early in the patient's illness.  For more information and maps of endemic areas check out the CDC or WHO websites:  http://www.cdc.gov/travel/notices/in-the-news/dengue-tropical-sub-tropical.htm or http://www.who.int/denguecontrol/en/

University of Maryland Section for Global Emergency Health

Author: Jenny Saltzberg

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Ultrasound-Guided Pericardiocentesis

• Though emergent pericardiocentesis is a relatively rare procedure in the ED, it is a critical intervention in patients with effusion and life-threatening instability/PEA arrest.
• Ultrasound-guided pericardiocentesis is preferred over the traditional "blind" approach, as it allows the provider to choose an optimal position and is associated with fewer complications.
• A few pearls when using ultrasound for emergent pericardiocentesis:
  • Consider placing an NGT for abdominal decompression.
  • Don't mistake the epicardial fat pad for an effusion; fat pads don't change size and usually move in concert with the ventricle.
  • The apical 4-chamber view tends to be the most common probe position, as the largest collection of fluid is usually around the apex.
  • If you are unsure about your needle location, inject 5-ml of agitated saline to confirm you are in the pericardial space.

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