Amiodarone-induced lung toxicity (ALT) is a serious and sometimes fatal complication of amiodarone use.
Symptoms range from mild (e.g., dyspnea with exertion) to acute respiratory distress syndrome and risk of death.
ALT is secondary to either release of toxic oxygen radials that are directly toxic to the lung or the reaction is secondary to an indirect immunologic reaction.
Risk factors for ALT: use > 2 months, dose > 400mg/day, advanced age, or pre-existing lung injury
ALT is typically a diagnosis of exclusion so suspect ALT through a detailed history; physical exam and radiology are non-specific. Lung biopsy is the only confirmatory test.
Treat ALT by discontinuing the drug, steroids, and supportive care. In rare cases where amiodarone cannot be safely discontinued (i.e., life-threatening arrhythmia), dosage should be reduced and steroids added immediately.
Generally, ALT is reversible with a good prognosis.
Show References
There are a handful of conditions associated with a rightward axis on the ECG: left posterior fascicular block, ventricular ectopy, lateral MI (old), pulmonary hypertension (acute or chronic), right ventricular hypertrophy, hyperkalemia, misplaced leads, and toxicity of sodium channel blocking drugs, to name a few.
When you notice that the rightward axis is NEW compared to an old ECG, and there's nothing else on the ECG that's obviously diagnostic (e.g. hyperkalemia would also show peaked Ts; ventricular tachycardia would be wide complex and fast, etc.), in emergency medicine you should always think first and foremost of the following three possibilities:
1. acute pulmonary embolus
2. toxicity of a sodium channel blocking drug
3. misplaced leads
Pay attention to axis! Using the above rule can make rightward axis very simple and useful.
AM
Show References
Pediatric forearm fractures:
- Splint distal forearm fractures in pronation in long-arm cast.
- While botulism is a rare condition (about 145 reported cases annually), it should still be considered in cases of descending neuromuscular weakness, as it can cause rapid loss of respiratory function and death (mortality < 8%). Check patient's vital capacity.
- Botulism results from ingesting (onset of symptoms 6 to 48 hours) or having contamination of a wound (onset 4-14 days; associated with intravenous drug use) with Clostridium botulinum, an anaerobic, spore-forming bacteria; it has been used as a bio-terrorist agent as well.
- Patients typically present with anticholinergic symptoms and the four "D's" - (1) dry moth, (2) dysarthria, (3) diplopia, and (4) dysphagia.
- The definitive diagnosis is made by isolating the toxin in serum and/or stool.
- Treatment is supportive and might include use of equine trivalent anti-toxin and human botulism immunoglobulin. Antibiotic and anti-cholinergic therapy has not been shown to be particularly effective.
Show References
The Crashing Patient with PAH
- In recent weeks, we've highlighted some pearls regarding the management of patients with pulmonary arterial hypertension (PAH).
- In the crashing patient with PAH, think about the following:
- Catheter occlusion or malfunction (for those receiving IV prostacyclin analogues)
- PE (for those inadequately anticoagulated)
- Pneumonia
- RV ischemia
- GI bleeding
- Ischemic bowel
- In the patient receiving IV epoprostenol (Flolan) who presents with a catheter occlusion or malfunction, time is of the essence. Restart the medication through a peripheral IV as soon as possible.
Show References
Metaphyseal bucket handle and corner fractures are almost pathognomonic for child abuse
These injuries were originally identified by clinicians evaluating children with subdural hematomas
These injuries are typically seen in the ankles, knees, elbows and wrists
Violent twisting, shaking, or pulling across a joint creates shearing forces across the weak epiphyseal growth plate and metaphysis
This leads to
1) A thin rim of mineralized metaphyseal bone aka “bucket handle”
http://rad.usuhs.mil/rad/home/peds/bucketarrow.jpg
OR
2) Small flecks of bone from the metaphyseal corner adherent to periosteum
http://t2.gstatic.com/images?q=tbn:ANd9GcT0kZ3VR1f7MwRj7oIa6jaYVp_-f8kZ1NhSbw4kCTRGNLDJ1pKK9g
- causes gastric outlet obstruction and vomiting
- 1 in every 500 infants; with a 4:1 male-to-female ratio and a family history in another sibling
- symptoms begin 2-4 weeks after birth, with projectile NON-bilious vomiting
- firm, mobile, nontender, olive-shaped mass in right hypochondrium or epigastric area
- diagnosis confirmed with US or upper GI series
- treatment is a pyloromyotomy, but fluid and electrolyte replacement is vital in ED
Show References
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.
Show References
- 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.
Show References
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.
Show References
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.
Show References
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….
Show References
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%.
Show References
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).
Show References
- 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:
- 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.)
- Does the patient have epilepsy? (defined a having at least 2 unprovoked epileptic seizures by any immediately identifiable cause.)
- 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.)
- 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.
Show References
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.
Show References
Question
9 year-old boy with sudden onset of unilateral facial swelling. What’s the diagnosis?
Show Answer
Show References
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