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:
- 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.
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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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Classic Kawasaki is diagnosed by fever for greater than 5 days plus 4 out of 5 classic signs.
- Mnemonic: “CRASH and burn”
- Conjunctivitis (bilateral and nonexudative)
- Rash (polymorphous, ie can look like anything)
- Adenopathy (cervical, usually greater than 1.5cm and usually unilateral)
- Strawberry tongue or other oral changes (lip swelling/fissuring/erythema/bleeding, oropharyngeal hyperemia)
- Hands and feet (induration and erythema, desquamation is a late sign)
- Burn = fever lasting for >5 days
But what about an 8 month-old with 6 days of fever plus nonexudative conjunctivitis, unilateral cervical adenopathy and a diffuse maculopapular rash? Send some labs!
Incomplete Kawasaki is defined as fever for >5 days with 2 or more of the classic findings plus elevated ESR (>40mm/hr) and CRP (>3.0mg/dL). It is most common in infants under 12 months of age.
Disposition for the 8 month-old?
- If ESR and CRP are not elevated, discharge to home with f/u in 24 hours to re-evaluate symptoms and for repeat labs if fever persists.
- If ESR and CRP are elevated, the child needs an echo to evaluate for coronary artery aneurysms.
If the echo is normal, follow up in 24-48 hours and will need a repeat echo if fever persists.
TREAT kids with IVIG and aspirin (which generally means admission) if echo is positive, or with normal echo and the presence of 3 or more supplemental criteria:
- Anemia for age
- Elevated ALT
- Albumin<3.0mg/dL,
- Sterile Pyuria (>10 WBC/hpf)
- Platelets >450K after 7 days
- WBC >15,000
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- 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:
- 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.
- 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.
- 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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- 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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Hypertensive Emergency Pearls
- Recent literature indicates that many patients with a true hypertensive emergency are mismanaged.
- Patients with a hypertensive emergency should have an arterial line placed and receive a continuous infusion of a short-acting, titratable medication to reduce blood pressure. Avoid oral, sublingual, and intermittent IV bolus administration of antihypertensives.
- Recall that most patients with a hypertensive emergency are volume depleted. Providing IV fluids can help to prevent marked drops blood pressure when you start an IV antihypertensive medication.
- Avoid diuretics (due to volume depletion) and hydralazine. Hydralazine can cause precipitous drops in blood pressure and is felt by many to have no role in the treatment of hypertensive emergencies.
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The 30-day mortality for patients < 65 years of age who are diagnosed with and treated for acute MI is 3%. In contrast, the 30-day mortality for patients > 85 years of age who are diagnosed with and treated for acute MI is 30%! Obviously the mortality is far higher if the patient's diagnosis is delayed or missed; or if the patient is not treated appropriately.
This simple statistic highlights the critical importance of being aggressive with diagnostic and therapeutic planning for elder patients with potential ACS. We cannot afford to be cavalier in their evaluation or treatment.
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Arthrocentesis of the Wrist
First locate and feel comfortable identifying two important landmarks:
1) Lister's tubercle is an elevation found in the center of the dorsal aspect of the distal end of the radius
http://www.aafp.org/afp/2004/0415/afp20040415p1941-f2.jpg
2) The extensor pollicis longus (EPL) tendon runs in a grove just radially to Lister's tubercle. Active extension of wrist and thumb aid with identification.
http://www.rad.washington.edu/academics/academic-sections/msk/muscle-atlas/upper-body/extensor-pollicis-longus/atlasImage
A) Positioning: Place wrist in ulnar deviation and 20 - 30 degrees of flexion. Apply longitudinal traction to the fingers of the hand.
B) Technique: Insert a small needle (22g) just distal to the tubercle and on the ulnar side of the EPL tendon.
http://img.medscape.com/pi/emed/ckb/clinical_procedures/79926-79928-80032-1477044tn.jpg
http://www.youtube.com/watch?v=nlPdb_mymw4&feature=related
http://www.youtube.com/watch?v=UVG7fZvZD-s&feature=related
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- ocurs with significant lateral traction during vaginal delivery of an infant
- results in damage to the upper part of the brachial plexus, especially the 5th and 6th cervical roots
- results in paralysis of hte shoulder and arm
- the affected arm is held in adduction and internal rotation
- most resolve spontaneoulsy, but some may require physical therapy after 2 weeks
- surgery is rarely required, and has poor results
- always palpate for ipsilateral clavicel fractures!
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Several medications have been linked to causing idiopathic intracranial hypertension (pseudotumor cerebri). Be sure to record an accurate medication history in patients you suspect of having this diagnosis.
- Excessive doses of vitamin A
- Other retinoids too: retinol, isotretinoin, and tretinoin
- Tetracyclines (tetracycline, doxycycline, minocycline)
- Growth hormone
Withdrawal of the offending agent will generally resolve the symptoms.
- Remember that lithium overdoses should not be treated with oral activated charcoal, as these charged particles are not adequately absorbed by this method.
- Instead, whole bowel irrigation using 500 mL to 2 liters of polyethylene glycol should be administered within the first 2-3 hours of presumed large ingestions (ie. at least 10 to 15 pills), with a goal of having the patient pass stool to the point of clear rectal effluent.
- Hemodialysis (HD) should be reserved to treat severe lithium toxicity, which is somewhat loosely defined as a serum level greater than 3.5 to 4 meq/L (mmol/L).
- For levels > 4 meq/L, most experts agree that HD should be performed regardless of whether associated symptoms are present. For levels > 2.5 meq/L with associated clinical signs/symptoms (i.e. tremulousness, dizziness, lethargy, seizure), conditions that would limit lithium excretion (i.e. renal insufficiency), or conditions that would limit ability to aggressively hydrate (i.e. CHF), HD should be performed.