- Angioedema is induced by elevated levels of bradykinin.
- Bradykinin is noramlly degraded by angiotensin-1 converting enzyme and several other enzymes (including aminipeptidase–P)
- A deficiency in aminopeptidase-P likely leads to ACE induced angioedema.
- Treatment typically starts with discontinuing ACE inhibitors, administering H1 and H2 antagonists, and corticosteroids (all Class indeterminate).
- Another consideration may be FFP 10-15 ml/kg IV or the off label use of icatibant (both Class II recommendations).
- Icatibant inhibits the bradykin B2 receptor. It is a sythetic decapeptide structurally similar to bradykin.
- Icatibant has been effective in case reports and case series in ACE induced angioedema. There is a prospective, double blind randomized placebo controlled trial underway.
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Diagnosis should be considered in any individual over 5 years old with severe dehydration from diarrhea, regardless of exposure to an endemic area, and any patient over 2 years old with watery diarrhea in an endemic area.
Patients with severe cholera can stool as much as 1 L an hour. Replacing fluids is the most important part of treatment with oral rehydration being used as soon as possible. Oral rehydration therapy provides better potassium, carbohydrate, and bicarbonate replacement than most IV fluid solutions. Antibiotics will also decrease volume and duration of stooling but are only recommended in moderate to severe illness. Antiemetics are not useful because they can make patients sleepy and will reduce their ability to rehydrate orally. Antimotility medications will prolong the duration of illness.
University of Maryland Section for Global Emergency Health
Author: Jenny Reifel Saltzberg
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Serotonin Toxicity in the Critically Ill
- Serotonin toxicity (aka serotonin syndrome) can easily be overlooked and misdiagnosed in many of our critically ill patients.
- Several common ED medications are associated with serotonin toxicity and include tramadol, linezolid, ondansetron, and metoclopramide.
- Clues to the diagnosis include hyperthermia, increased muscle tone, hyperreflexia, dilated pupils and clonus. Of these, clonus is the most sensitive and specific sign.
- A few important treatment pearls:
- Avoid physical restraints
- Consider cyproheptadine: only available in PO form; initial dose is 12 mg
- Avoid dopamine for those that need vasopressors
- Avoid bromocriptine and dantrolene
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Question
33 year-old male in respiratory distress. What's the diagnosis?
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EPSS is an accurate and rapid bedside estimation of left ventricular function
First an image of heart should be obtained in the parasternal long-axis view
The ultrasound cursor should be placed through the anterior leaflet of the mitral valve
Subsequently, M-mode is applied and the distance between the anterior leaflet and the interventricular septum is measured during early diastole
A measurement of 7mm or greater indicates poor EF (see attachment below)
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Attachments
Distal radius fractures are common in children
Traditional management includes closed reduction +/- procedural sedation
The downside of this approach includes: patient risks, cost, physician time, ED bed time and tying up resources.
Kids have excellent bone remodeling potential...displaced and angulated fractures heal well without reduction
Crawford et al - 51 children aged 3 to 10 (avg 6.9 yrs) w/closed distal radius fractures.
Exclusions: open or growth plate fractures, metabolic bone disease or neurovascular injury.
No sedation, analgesia or fracture reduction was performed
Treatment: simple casting and gentle molding to correct angulation... i.e. fractures were left in a shortened, overriding position
Outcome: All patients had clinical and radiographic union and full range of motion of the wrist at one year w/ good patient (parent) satisfaction. This was associated w/ significant cost savings.
Consider this approach in consultation with orthopedist
Remember exclusions: open fractures, fracture dislocations, growth plate injuries and neurovascular injury.
Children w/ excessive angulation or rotational deformity should have standard care (closed reduction w/ sedation)
Multiple guidelines exist for "excessive angulation" but as a general rule
Age < 5 Up to 35 degrees
Age 5- 10 Up to 25 degrees
Age >10 Up to 20 degrees
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- The differential of child with stridor <6m:
- Tips for the treatment of croup:
As everyone knows by now the New England Compounding Company has been implicated in contaminated steroid vials that were used for epidural injections. Patients that have pleocytosis on CSF after lumber puncture will be admitted and started on liposomal amphotericin B and IV voriconozaole.
IV Voriconazole Adverse Effects:
Vivid visual hallucinations
Visual Disturbances - 30 min after administration: Blurry, photosensitivity
Hepatotoxitcity
Photoxicity - associated with increased risk of squamous cell CA of the skin
- Causative organism: members of the genus Borrelia
- Louse Borne Relapsing Fever (LBRF)
- Human body louse (Pediculus humanus)
- Associated with sporadic outbreaks especially in areas with large refugee populations
- Tick Borne Relapsing Fever (TBRF)
- Soft ticks of the genus Ornithodoros
- Typically found in higher elevations of the western United States as well as the central plateau region of Mexico, Central and South America and Africa
- Louse Borne Relapsing Fever (LBRF)
- Clinical Presentation
- Symptoms develop 3 to 18 days after infection.
- Onset is abrupt and may include fever, malaise, headache, arthralgias, nausea and vomiting and cough.
- The first febrile episode lasts 3 to 6 days and then recurrences may occur after 7 to 10 days.
- Diagnosis
- Definitive diagnosis: visualization of spirochetes on peripheral blood smear.
- May also see leukocytosis, anemia and/or thrombocytopenia, elevation of liver function tests
- Erythrocyte rosette formation may be present.
- Treatment
- Antibiotics recommended for treatment include penicillin, doxycycline and erythromycin.
- Jarisch-Herxheimer reaction common after treatment. This can be life threatening and all patients undergoing treatment should be closely monitored.
University of Maryland Section for Global Emergency Health
Author: Gentry Wilkerson
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Question
Trauma patient (...yes, that's the only history you're given). Diagnosis?
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Cardiac amyloidosis can present along a spectrum from asymptomatic to severe CHF w/conduction abnormalities
ECG with low voltage + echocardiogram with thickened myocardium should heighten suspicion
Definitive Dx. is myocardial biopsy identifying the infiltrative lesion (MRI w/gad is also supportive)
AL (light chain) amyloidosis is an acquired disease from improperly functioning plasma cells
¨ Rapidly progressive and life threatening
¨ Tx. w/chemotherapeutic agents (+/- BMT)
Transthyretin-related (TTR) amyloidosis is produced by the liver (2 types)
Familial transthyretin-related amyloidosis (ATTR)
Senile systemic amyloidosis (SSA)
¨ Both are slowly progressive
¨ Tx liver transplant (ATTR) and supportive care (SSA)
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Many who work in urban EDs and have a patient population that has a high rate of methadone use have probably wondered - why don't I see many STEMIs in the ED?
One study has actually attempted to answer the question - is methadone cardioprotective? Comparing 98 decedents with known long-term methadone exposure and compared autopsy coronary artery findings to match controls without, there was significant decrease in incidence of severe CAD:
5/98 Methadone Patients post-mortem had severe CAD vs 16/97 match controls
Better than a baby ASA, who knew?
[I thank Dr. Hoffman for citing this article to me]
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Delirium in the Critically Ill
- Delirium has been shown to be an independent predictor of mortality and can occur in up to 75% of critically ill patients.
- Whether preventing or treating delirium in the critically ill patient, consider the following:
- Minimize the use of anticholinergic medications (i.e. diphenhydramine, chlorpromazine)
- Ensure pain is adequately controlled (avoid meperidine and tramadol)
- Be careful with sedative medications; consider bolus dosing and daily interruption of continuous infusions
- Additional measures to treat delirious patients include reducing sensory deprivation, promoting normal sleep-wake cycles, early physical rehabilitation, and treating psychosis.
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Question
35 year-old male unrestrained driver following motor vehicle crash presents with blunt chest injury. There are multiple injuries on CXR (can you find them all?), but what's up with his right lung?
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Etiological agent is the parasite Trypanosoma cruzi
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Congratulations to today's Baltimore marathoners and the medical race staff
In honor of them:
Marathons are becoming increasingly popular with participation rising from an estimated 143,000 US marathon finishers in 1980 to a record high of 507,000 during 2010.
Most victims of exercise-related sudden cardiac arrest have NO premonitory symptoms
Autopsy reports show that
1) 65 - 70% of all adult sudden cardiac deaths are attributable to coronary artery disease.
2) 10% due to other structural heart diseases (HOCM, congenital artery abnormalities)
3) 5 - 10% due to primary cardiac conduction disorders (prolonged QT, ion channel disorders)
4) Remainder are due to non cardiac etiologies
Overall risk of sudden cardiac arrest is approximately from 1 in 57,000 and the risk of sudden cardiac death is approximately 1 in 171,000. Mortality without intervention after sudden cardiac arrest is greater than 95%. The majority occur in middle to late aged males.
V fib/V tach are the most common arrhythmias leading to sudden cardiac arrest. Most events occur in the last 4 miles of the racecourse.
Survival decreases by 7 - 10% with each minute of delayed defibrillation. Defibrillation within 3 minutes can produce survival rates as high as 67 - 74%. After 8 minutes, there is a dramatic decrease in survival. Prompt CPR increases survival from 2.5% to greater than 8%.
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- approximately 1% of children in DKA have some degree of cerebral edema, and up to 25% of them may die
- known risk factors include the following:
- younger children (especially <5 years)
- new onset or newly diagnosed
- increased BUN at presentation
- severity of acidosis at presentation
- bicarbonate therapy use
- failure of sodium to improve following therapy
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Activated charcoal is most effective if given within 1 hour of overdose.
Prehospital administration of charcoal can be challenging, but may save significant time compared to waiting until arrival to the ED. The patient has to be transported by EMS, registered, seen by a provider, order for charocal placed...
Two studies evaluated the time difference between prehospital and hospital administration of GI decontamination.
- Study 1 found median time to activated charcoal in the ED was 82 minutes.
- Study 2 found mean time to activated charcoal by EMS was 5 minutes, compared to 51 if held until arrival to ED.
Bottom line: Don't underestimate the amount of time that goes by before you evaluate non-crashing patients upon arrival to the ED. If the story supports an overdose and the patient doesn't have contraindications for receiving charcoal, recommend it be given in the prehospital setting for greatest potential benefit.