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.
Show References
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
Attachments
- 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.
Show References
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.
Show References
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.
Show References
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
Show References
- 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!
Show References
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.
Show References
Positive-pressure ventilation (e.g., mechanical ventilation) increases intrathoracic pressure potentially reducing venous return, right-ventricular filling, and cardiac output.
Pericardial tamponade similarly causes hemodynamic compromise through increased pericardial pressure which reduces right-ventricular filling and cardiac output.
When mechanically ventilating a patient with known or suspected pericardial tamponade the mechanisms above may be additive, causing cardiovascular collapse and possibly PEA arrest.
For the patient with known or suspected pericardial tamponade consider draining the pericardial effusion prior to intubation or delaying intubation until absolutely necessary.
If intubation is unavoidable, consider maintaining the intrathoracic pressure as low as possible (by keeping the PEEP and tidal volumes to a minimum) to ensure adequate cardiac filling and cardiac output.
Show References
Blood pressure cuffs tend to OVERESTIMATE true blood pressure in obese patients. Even larger cuffs tend to do this as well. While low blood pressures are often reliable in diagnosing shock, be wary of assuming a "normal" blood pressure (e.g. SBP 100-120s) rules out shock in an obese patient who is sick. A-lines might be necessary to accurately assess the blood pressure.
[adapted from ACEP talk by Dr. Tiffany Osborn]
A recent randomized trial compared nicardipine as a continuous infusion to labetalol boluses to determine which one was more effective at lowering blood pressure to a target range within 30 minutes.
Median initial SBP for the 226 patients was 212 mm Hg. Within 30 minutes, nicardipine patients more often reached target range than labetalol (91.7 vs. 82.5%, P = 0.039). Of 6 BP measures (taken every 5 minutes) during the study period, nicardipine patients had higher rates of five and six instances within target range than labetalol (47.3% vs. 32.8%, P = 0.026).
What this means: Nicardipine is a reasonable choice for patients needing acute lowering of blood pressure (e.g., ischemic stroke with tPa). Nicardipine seems to achieve faster and smoother lowering of blood pressure than labetalol therapy with less blood pressure readings outside the target range.
Show References
Salicylates:
- stimulate the respiratory center in the brainstem, causing respiratory alkalosis
- interfere with the Krebs cycle, limiting ATP production, leading to an anaerobic metabolism
- uncouple oxidative phosphorylation, causing accumulation of pyruvic and lactic acid and heat production, resulting in acidosis and hyperthermia
- increase fatty acid metabolism, generating ketone bodies
Overall, this results in a mixed respiratory alkalosis and metabolic acidosis.
Show References
- A huge limitation to effectively managing acute ischemic stroke in rural areas is the frequent lack of access to local experts in vascular neurology. While most guidelines encourage the use of telemedicine to overcome such barriers, the start up costs of such programs are sometimes prohibitive, particularly for small, rural practices.
- A recent, small study showed that providers may be able to use the iPhone as a primary or adjunctive tool with telemedicine, to properly diagnose and manage acute stroke.
- The study compared a face-to-face provider's NIH Stroke Scale (NIHSS) interpretation to that of a remote provider using an iPhone with FaceTime software that allows real-time streaming of audio and video.
- Agreement between providers was excellent (intraclass correlation coefficient 0.98); the NIHSS score of the providers did not differ by more than 1 point in 17 of the 20 cases; in only one category - ataxia - was agreement poor.
- TAKE HOME POINT: Streaming real-time video technology may offer an effective and economically feasible alternative to suboptimal acute stroke care in rural areas or an alternative/adjunct to pure telemedicine programs. (This is not an advertisement or endorsement for the iPhone.)
Show References
Mechanical Ventilation in Patients with Pulmonary HTN
- In the critically ill patient with pulmonary HTN and respiratory failure, improper mechanical ventilator settings can be disastrous.
- Large lung volumes and high levels of PEEP can result in acute cardiovascular collapse.
- When setting the ventilator is these patients, select low tidal volumes and relatively low levels of PEEP (3-5 cm H2O).
- In addition, small studies suggest avoiding permissive hypercapnia, as this may increase pulmonary vascular resistance and mean pulmonary arterial pressure.
Show References
Question
72 year-old man, one-week post right fem-pop bypass presents with painful blue and black toe. Diagnosis?
Show Answer
Show References
Today's cardiology pearl provided by EMS guru Dr. Ben Lawner. Consider this one if you are caring for a patient with what appears to be shock-resistant VFib.
An intervention that has its roots in the electrophysiology lab has now gained traction on the front lines of resuscitation: double sequential defibrillation. Prospective studies are currently underway to examine the feasibility of this technique. New Orleans (LA) EMS boasts several anectodal accounts of survival, with neurologically intact recovery, from refractory ventricular fibrillation. The next time you can’t stop the fibbing, consider this:
· Apply TWO sets of defibrillator pads to the patient; one in traditional sternum/apex configuration and the other in anterior/posterior configuration
· If ventricular fibrillation persists despite several shocks, coordinate the simultaneous firing of BOTH defibrillators
Some caveats:
This treatment is based upon EP lab data; each MONOPHASIC defibrillator was set at 360J. EMS services in New Orleans and Wake County (NC) have used two biphasic defibrillators, each set a 200J. There is not sufficient data to make any widespread recommendation, but the idea of double sequential defibrillation may be another tool in a limited ACLS bag of tricks for patients who simply cannot come out of V-fib. New Orleans EMS has initiated the double-defib protocol after four shocks, and Wake County’s protocol recommends initiation after five. Wake's protocol also recommends firing the defirbillators "as synchronously as possible."
Show References
Methotrexate is a chemotherapeutic that is utilized in non-Hodgkin lymphoma and breast CA. It is also used as an immunosuppressant for rheumatoid arthritis and psoriasis. Finally, we see it used in the ED for the treatment of ectopic pregnancy. Overdose, often unintentional, can have a lethal outcome.
Toxicity: LFTs rise, N/V, stomatitis, mucositis, leukopenia, thrombocytopenia, renal failure
Antidote: Leukovorin (Folinic Acid)
Other Tx: Carboxypeptidase G2, Charcoal Hemoperfusion, HD (possible)
- Myasthenia Graves (MG) is often associated with several, distinct clinical findings which patients may have during their crisis in the emergency department. These findings may include the following:
- Mask-like face
- Eyelid weakness
-- leads to ptosis
-- exacerbated by sustained upward gaze
-- improved by closing the eyes for a short while
- Extraocular motion abnormality
-- usually affects more than one extraocular muscle
-- may be assymetrical
-- may result in mild proptosis
- Weak palatal muscles
-- nasal-sounding voice
-- nasal regurgitation of food
- Weak jaw muscles
- Absent gag reflex
- Pupils normal