Vitamin B12 deficiency can cause significant disease, including severe neurologic problems. However, patient presentations can vary greatly.
Signs and symptoms can include:
- Constitutional symptoms: fatigue, lack of energy, lightheadedness, loss of appetite
- Gastrointestinal problems: diarrhea or constipation
- Cardiovascular: shortness of breath, dyspnea on exertion, tachycardia, CHF
- Oral lesions: swollen, red tongue (glossitis) or bleeding gums
- Problems concentrating
Prolonged B12 deficiency can lead to significant neurologic complications, frequently related to the spinal cord, and can include:
- Mild impairment to dementia
- Depression, psychosis
- Loss of balance, limb weakness, ataxia
- Peripheral neuropathy (numbness and tingling of hands and feet)
PaCO2 and the Post-Arrest Patient
- Alterations in PaCO2 are common during the post-arrest period and have been associated with worse patient centered outcomes.
- Hypercarbia can dilate cerebral vessels, increase cerebral blood flow, and may increase intracranial pressure.
- Conversely, hypocarbia can constrict cerebral vessels and may reduce cerebral blood flow.
- Though the current evidence is primarily limited to observational trials, a recent meta-analysis found that "normocarbia" was associated with improved hospital survival and neurologic outcome.
- Take Home: Adjust mechanical ventilation to target normocarbia (PaCO2 or ETCO2) in the post-arrest patient.
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Question
A 36-year-old male, who recently immigrated from Africa, presented to the ED with fever, rash, cough and shortness of breath. He was noted to be febrile to 39.0 C. The rash is disseminated but present mainly in his trunk as shown in the picture.
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Take Home Point:
- According to a recent article in the NEJM there does not seem to be any difference in the rate of symptomatic venous thromboembolism (VTE) in patients given low molecular weight heparin that underwent arthorscopy or had lower leg casting at 3 months.
- Overall, the rates of VTE were really low ( casting: 1.4% vs. 1.8%; arthroscopy: 0.7% vs. 0.4%), so there is probably not need for prophalaxis in these patients.
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In pediatrics, providers typically prescribe 10 mg/kg (max 500 mg) and 5 mg/kg daily x 4 (max 250 mg) for treatment of pneumonia, but this dosing regimen is NOT recommended for all azithromycin usage. There are other dosing regimens that are important to keep in mind during the respiratory season:
1) Pharyngitis/ tonsillitis (ages 2-15 yr): 12 mg/kg daily x 5 days (max 500 mg/ 24 hr)
2) Pertussis
3) Acute sinusitis >/= 6 months: 10 mg/kg daily x 3 days
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Smoke inhalation victims (house fires) are at risk of carbon monoxide (CO) and cyanide poisoning (CN). CO exposure/poisoning can be readily evaluated by CO - Oximetry but CN level can be obtained in majority of the hospital.
Lactic acid level is often sent to evaluate for CN poisoning.
Bottom line:
- Lactatic acid levels should be sent in all smoke inhalation victims.
- Elevate lactate > 10 mmol/L is highly suggestive of CN poisoning
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It is well known that the early aggressive utilization of IV nitrates and non-invasive positive pressure ventilation (NIV) in patients presenting with acute pulmonary edema will decrease the number of patients requiring endotracheal intubation and mechanical ventilation.
Often our tepid dosing of nitroglycerine is to blame for treatment failure. Multiple studies have demonstrated the advantages of bolus dose nitroglycerine in the early management of patients with acute pulmonary edema. In these cohorts, patients bolused with impressively high doses of IV nitrates every 5 minutes, are intuabted less frequently than patients who received a standard infusion (1,2). No concerning drops in blood pressure in the patients who received bolus doses of nitrates were observed. Using the standard 200 micrograms/ml nitroglycerine concentration, blood pressure can be rapidly titrated to effect.
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Concussions are associated with an elevated risk of musculoskeletal injury
Significant associations were found between concussion and
Lateral ankle sprain (P = 0.012)
Knee injury (P = 0.002)
Lower extremity muscle injury (P = 0.031)
Keep in mind that 50 – 80% of concussions may go undiagnosed or unreported.
A discussion about risks of early return after concussion should include mention of risks beyond repeat head injury/2nd impact syndrome
Study limits: Retrospective design limits ability to establish causation/reporting bias
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Vitamin B12 deficiency, including pernicious anemia, is typically seen in malnourished individuals. Globally, it is widespread in those who live in poverty.
In the U.S., we often consider it in individuals who are chronic alcoholics. However, it can be seen in others, including:
- Bariatric patients after certain weight-loss surgeries
- Conditions causing problems with food digestion, including Crohn’s disease, celiac disease, or fish tapeworm (Diphyllobothrium latum) infection
- Individuals on certain medications for a prolonged time, including proton pump inhibitors, histamine 2 receptor blockers and metformin
- Inadequate dietary intake or genetic intrinsic factor deficiency
The Neurocritical Care Society and Society of Critical Care Medicine just came out with new Guidelines for Reversal of Antithrombotics in Intracranial Hemorrhage (ICH) [1]
--PCC is now recommended over FFP in reversal of vitamin K antagonists (VKA) with elevated INR. Either should be co-administered with 10mg IV vitamin K. (Strong recommendation, moderate quality evidence)
TAKE AWAY: PCC should be probably be given over FFP in VKA-ICH when available
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Take home points:
- Cellulitis is overdiagnosed
- 1/3 of patients diagnosed with cellulitis in the ED are ultimately given a different diagnosis
- The most common final diagnoses are vascular or inflammatory conditions.
- The over treatment of cellulitis increases healthcare costs, increases risk of adverse reactions, and can contribute to the development of drug resistant organisms.
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Acetaminophen is one of the most common pharmaceutical ingestions in overdose and a leading cause of acute of liver failure in the U.S. Early recognition and treatment is critical for prevention of morbidity.
- Vigilance and screening is required for this "silent poison", available in hundreds of OTC products and in combination with numerous prescription medications. Symptoms may not be present early in course (for up to 24 hours) in poisoning.
- Maximal benefit with antidote treatment, n-acetylcysteine (NAC) is time dependent within 8 hours of ingestion. Fulminant hepatotoxicity is unusual in acute overdoses treated with NAC within 10 hours of ingestion.
- Early prediction of poor prognosis is essential to identify patients who may require life-saving liver transplantation. Kings College Criteria: Arterial pH less than 7.30, INR greater than 6.5, Creatinine greater than 3.4, Grade III or IV encephalopathy combined with Lactate greater than 3.5 and Phosphate greater than 3.75 may increase sensitivity.
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Impact of an ED pharmacist on time to thrombolysis in acute ischemic stroke
- Prior studies showed that incorporation of ED pharmacists within ED clinical teams lead to more rapid treatment of trauma, stroke, and STEMI.
- A recent retrospective study conducted by Montgomery et al. showed that having an ED pharmacist on the stroke alert team increased the number of patients meeting goal door-to-needle time of 60 minutes.
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Mechanical Ventilation in the Obese Patient
- Obesity can result in decreased lung volumes, decreased lung and chest wall compliance, and increased work of breathing.
- Unfortunately, there is very little literature to guide the emergency physician on mechanical ventilation in obese patients.
- A recent study of intubated ED patients by Goyal, et al found that over 1 in 5 patients were ventilated with potentially injurious tidal volumes.
- Importantly, obesity increased the odds of inappropriate ventilator settings.
- In the intubated obese patient, be sure to set tidal volume based on ideal body weight and consider starting with a higher PEEP setting (i.e., 10 to 15 cm H2O).
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Question
30 Year-old female presents to the ED for a rash. The rash started suddenly, mainly in her extremities and it is painful. The patient denied having fever or chills. Her past medical history is unremarkable. She admits to using cocaine frequently. The rash is shown in the picture.
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Recent study evaluated whether an acetaminophen (APAP) level obtained less than 4-hour post acute ingestion can predict which patient would not require n-acetylcysteine (NAC). APAP cutoff level of 100 ug/mL was used for analysis. This was a secondary analysis of the Canadian Acetaminophen Overdose Study database (retrospective study).
Bottom line:
- If initial APAP level of 100 ug/mL was applied as a cutoff point, it missed 27 patients (N= 1821) who had toxic APAP level at > 4-hour post ingestion that require NAC.
- Only a very low (< 15 ug/mL) or undetectable initial APAP reliably identify (sensitivity 100%) patients who do not require NAC.
- Absorption of APAP can be delayed by coingestion of opioids or antimuscarinics.
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The prognosis of patients who experienced OHCA, who have not achieved ROSC by the time they present to the Emergency Department, is dismal. As such, it behooves us as Emergency Physicians to identify the few patients with a potentially survivable event. Drennan et al examined the ROC data base and identified the cohort of patients who had not achieved ROSC and were transported to the hospital. The overall survival in this cohort was 2.0%. Factors that predicted survival were initial shockable rhythm and arrest witnessed by the EMS providers. Patients arriving to the ED without ROSC, that had neither of those prognostic factors had a survival rate of 0.7%.
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Question
27 year-old G2P1 presents with 3 days of abdominal pain that is mostly suprapubic. Denies any urinary symptoms and vaginal bleeding. Physical examination reveals slight rebound in the right lower quadrant.
An ultrasound revealed the following. What's the diagnosis?
