• Phenytoin (Dilantin) should not be infused at a rate greater than 50 mg/minute, to a total of 20 mg/kg.

• Caution is encouraged while infusing due to the risk of inducing hypotension and cardiac arrhythmias, making cardiac monitoring during infusion mandatory.

• These adverse effects are partly related to the propylene glycol used to solubilize phenytoin.

• Additionally, the risk of local pain and injury, such as venous thrombosis and the purple glove syndrome, increases with rapid infusion rates.

Dopamine in the ED

• Recall that dopamine is an endogenous catecholamine that is a precursor for norepinephrine synthesis
• Despite the popularity of norepinephrine, dopamine is still used by many EPs in the setting of septic shock
• Dopamine produces progressive alpha-receptor stimulation at doses > 10 mcg/kg/min
• Tachyarrhythmias (namely sinus tachycardia) is the predominant adverse effect
• When selecting a vasopressor agent, be sure to check the HR.  If the patient is already tachycardic, the addition of dopamine will only worsen the tachycardia
• Additional important adverse effects are increased intraocular pressure and delayed gastric emptying

Healthcare Associated Pneumonia (HCAP)....why is this important for the emergency physician?

Most of us are very familiar with the types of pneumonias commonly seen in clinical practice: community-acquired pneumonia (CAP), hospital-acquired pneumonia(HAP), and ventilator-associated pneumonia (VAP). But, some may not be that aware of a relatively newer type of pneumonia that has been well-defined, healthcare-associated pnemonia (HCAP). Experts in infectious disease and critical care now say that we (the ED) should be assessing ALL pneumonia patients for HCAP risk factors.

Why care, you ask?

• Higher mortality than CAP
• May look like CAP
• Treated much differently than CAP

Risk factors: (most are common sense)

• Nursing home or extended care facility resident
• Recently admiited to a hospital for 2 or more days in the preceeding 90 days
• Home wound care or attending a clinic for wound care
• Dialysis patient
• Home infusion therapy (antibiotics)
• Immunosuppresive therapy or disease

Treatment:

• 3 drugs....not like treatment of CAP!
• Usually a combination of a big gun anti-pseudomonal (e.g. Pip/Tazo) combined with a broad spectrum respiratory fluoroquinolone (e.g. Moxi), combined with Vancomycin
• Key difference between treatment of CAP and HCAP is consideration for multi-drug resistant pathogens, pseudomonas, and MRSA.

Death from ruptured aortic aneurysms and thoracic aortic dissection has a few key features that often help in distinguishing these entities from other causes of rapid decompensation and sudden death:
1. These aortic disasters have a tendency to present with hypotension but without necessarily any specific complaints of pain (in contrast to common teaching).
2. These aortic disasters tend usually to produce PEA as the initial arrest rhythm.
3. These aortic disasters are often diagnosable on bedside ultrasound (AAA seen when scanning the abdomen; dissections frequently produce pericardial tamponade as they dissect backwards into the pericardial sack).

ALWAYS take a look at a patient's aorta and pericardium with the ultrasound when that patient presents in extremis or in cardiac arrest. The results can help make some critical diagnostic and therapeutic decisions.

[recent article related to this topic: Pierce LC, Courtney DM. Clinical characteristics of aortic aneurysm and dissection as a cause of sudden death in outpatients. Am J Emerg Med 2008;26:1042-1046.]

The glucometer is one of the devices that we quickly reach for in the management of our unresponsive patients, diabetics and in the critically ill.  Recently, I noticed that our Roche Accu-Check has a big sticker on the case stating that results could be affected by therapies that alter the metabolism of galactose, maltose, and xylose.  Since this was a big hole in my fund of knowledge I decided to look up what else affects the accuracy of glucometers.

 Now, Dr. Winters already warned used about the inaccuracy of bedside glucometer readings in the critically ill, but what about the patient that is not septic and/or in shock.

Substances/Drugs that have been reported to affect the accuracy of glucometers are:

• Levodopa
• Dopamine
• Mannitol
• Acetaminophen
• Severe lipemia
• Severe unconguted bilirubin
• Elevated Uric Acid
• Maltose (present in immunoglobin products)
• Patient on peritoneal dialysis secondary to Icodextrin
• Ascorbic Acid (Vitamin C)

Anemia also results in higher values, and a capillary blood sample can differ from venous blood by as much as 70mg/dL.

Most errors are more significant when dealing with hypoglycemia. 

So the moral of the story is be careful with a bedside glucometer when the reading is low, as the venous blood sample sent to the lab may return even lower.  Error on the side of treating the patient with glucose.

• Exact definitions of status epilepticus vary. 

• Generally speaking, status epilepticus is defined as a single unremitting seizure that lasts longer than 5 to 10 minutes OR greater than one generalized clinical seizure with no interictal return to clinical baseline.

• While treatment with phenytoin and diazepam is often used for status, studies have shown that lorazepam use alone is more effective. 

Seizures in the Critically Ill

• Seizures are a common complication in medical and surgical patients commonly arising from coexisting conditions associated with critical illness
• Most seizures in the critically ill are generalized convulsions rather than focal
• The majority of seizures occur in patients without a pre-existing history of seizure disorder
• Common causes of seizures in the critically ill include sepsis, cardiovascular disease, metabolic abnormalities, medications, and drug intoxication/withdrawal
• Metabolic abnormalities account for 30 -35% of causes
• The most common metabolic abnormalities include hyponatremia, hypocalcemia, hypophosphatemia, uremia, and hypoglycemia
• Be sure to check these labs in ICU patients with a seizure

This is a psychoactive herb which can induce strong dissociative effects by stimulation of the kappa receptor. It has become increasingly well known and available in modern culture, and popularized by YouTube Salvia (also known as Sage, Diviner's Sage, Magic Mint, or Sally D) is usually smoked, but can be chewed or ingested.

The high it produces is very intense, but lasts only approximately 10 minutes. Currently many states have enacted legislation against it, including Fla, IL, KA, MI, MO, ND, OK and VA, but it is available over the internet.

The following video demonstrates clinical effects of drug.
Although it is amusing, this is not meant to condone use.

(if you can not view the embeded video here is the link)

http://www.youtube.com/watch?v=w6dgXX0ytSo

• Chiari Malformations are congenital abnormalities wherein the cerebellum downwardly displaces into the spinal canal.
• This results in an increase in pressure and subsequent obstruction of CSF flow.
• Common symptoms associated with Chiari Malformations include:

              -  vertigo

              -  headache

              -  muscle weakness

              -  coordination abnormalities

              -  gait abnormalities

              -  visual abnormalities

How many times have you had a patient with an allergy to codeine described as stomach upset?  Or how about a rash with morphine (probably secondary to histamine release)?  True anaphylactic reactions to opioids are very rare (< 1%).  But what happens when you have a patient with a true allergy, but still need to give an opioid?  No problem, you just need to choose one that is structurally different.

• Group 1 (aka opiates) - Naturally occurring agents derived from the opium plant
  • Morphine, codeine, thebaine
• Group 2 - Semi-synthetics
  • Hydrocodone, oxycodone, hydromorphone, oxymorphone, buprenorphine (heroin is also in this group)
• Group 3 - Synthetics
  • Fentanyl (alfentanil, sufentanil, etc.), methadone, tramadol, propoxyphene, meperidine

All of the group 1 and 2 agents are structurally very similar to each other and should not be given if a true allergy exists to any other natural or semi-synthetic derivative.  Group 3 agents have structures different enough that they can be given to a patient intolerant to the natural or semi-synthetics without fear of cross reactivity.  They are also very different from others in this same group.

Auto-PEEP in the non-COPD patient

• In previous pearls we have discussed the concept of auto-peep in patients with expiratory flow limitation (asthma and COPD)
• Unexpected auto-peep can also occur in up to 35% of patients without asthma or COPD
• In these patients, auto-PEEP typically occurs with high minute ventilations (> 20 L/min) with shortened exhalation times or if exhalation is blocked (blocked ETT, exhalation valve, or PEEP valve)
• Recall that auto-PEEP increases the work of breathing, worsens gas exchange, and can cause hemodynamic compromise 
• Treatment of auto-PEEP can be as follows:
  • Change ventilator settings
    • increase expiratory time
    • decrease respiratory rate
    • decrease tidal volume
  • Reduce ventilatory demand
    • reduce anxiety, pain, fever with sedatives
  • Reduce flow resistance
    • large-bore ETT
    • frequent suctioning
  • Apply external PEEP

The classic risk factors for coronary artery disease (e.g. hypertension, diabetes, smoking, etc.) are helpful at predicting the long-term risk of CAD, but they have limited utility at predicting whether a patient with acute symptoms is having an acute coronary syndrome or not. In one recent study of > 800 patients with suspected cardiac chest pain, 12% of patients with NO cardiac risk factors ruled-in for acute MI.

Never rule out ACS in a patient purely based on the absence of traditional cardiac risk factors!

[Body R, McDowell G, Carley S, et al. Do risk factors for chronic coronary heart disease help diagnose acute myocardial infarction in the Emergency Department? Resuscitation 2008;79:41-45.]

A maisonneuve fracture is a fracture dislocation resulting from external rotational forces to ankle -- through interosseous ligament to fibula.

• Proximal fibula fracture - from external rotational forces (spiral/oblique)
• Ankle components can include any of the following:
  • medial maleolus avulsion fx or deltoid ligament rupture
  • anterior talofibular ligament rupture
  • interosseous ligament rupture
  • posterior malleolar fracture

If stability is questionable, orthopedic evaluation under anesthesia is required. Additionally always consider compartment syndrome. Do not rely on Kanduval's signs (pain, paraesthesia, pallor, poikilothermia, pulselessness) - "... with the exception of pain and paraesthesia, these traditional signs are not reliable." Emergent orthopedic consultation and compartment pressure assessment should be performed. (see attached photos)

High altitude illnesses is typically called Acute mountain sickness (AMS) and is associated with two major complications high altitude pulmonary edema (HAPE) and high altitude cerebral edema (HACE).

Symptoms associated with AMS are headache, fatigue, nausea and vomiting, anorexia and insomia. Cough, Cyanosis, hypoxia, and dyspnea are associated with HAPE.  HACE is associated with progressive neurologic symptoms and can lead to ataxia and coma.

Factors that increase your risk for altitude illnesses are:

• Rate of ascent
• Elevation obtained
• Exertion on arrival to elevation
• Duration at that altitude
• Recent URI
• Previous symptoms of AMS

How do we know if we really need to put all those red eyes sent in from daycare centers and schools on antibiotics? The following study shows us why.

Bacterial Conjunctivitis in Children

• Prospective study in a children’s hospital ED
• Conjunctival swabs for culture were obtained from patients aged 1 mo - 18 yrs presenting with red or pink eye and/or the diagnosis of conjunctivitis
• 111 patients enrolled over one year
• Mean age of 33.2 mos, 55% male
• 87 patients (78%) had positive bacterial cultures
  • Nontypeable H influenzae = 82%
  • S pneumoniae = 16%
  • Staphylococcus aureus = 2.2%
• The combination of a history of gluey or sticky eyelids and the physical finding of mucoid or purulent discharge had a post-test probability of 96% that the infection was bacterial.(So when both these are present you definitely should treat)
• And since the majority of these children (78%) had positive cultures even if they only had a pink eye it is reasonable to use empirical ophthalmic antibiotic therapy in children who present with the complaint of a pink eye.

Methylenedioxymethamphetamine (MDMA) or "Ecstasy"

A designer club drug that has been classified as a "hallucinogenic" amphetamine though it does not cause visual hallucinations like are reported with LSD. It has many of the sympathomimetic effects like other amphetamines but its main mechanism of action which both causes the euphoria and toxicity is serotonin agonism. Since Anti-diuretic hormone is released by the hypothalamus under the direct regulation of serotonin, there is a transient but dangerous episode of Syndrome of Inappropriate ADH (SIADH). Combined with the club culture and fear of dehydration while taking MDMA, patients ingest MDMA concomitantly with free water through the night further exacerbating the hyponatremia. The time sequence of events for these patient is (women appear genetically predisposed to this phenomena):

• Friday Night: Ingestion of MDMA (even one pill is enough) +/- free water
• Saturday Morning: headache, nausea, vomiting
• Saturday Afternoon: (Realizes its not a hangover) patient becomes confused progressing to unresponsive and eventually seizures
• Saturday Evening: Presents to ED with seizures

Treatment: Fluid restriction - this is the one time that the 1L NS Bolus can kill a patient with cerebral edema. If you must give fluid give 3% NaCl if there is symptomatic hyponatremia. Remember the patient has dropped their sodium in about 24 hours so you can replenish in about the same time quite safely and even faster in severe cases. Treated correctly, patients improve rapidly - within 24-48 hours. Read a great case report in the reference below.

• It is crucial to be familiar with and use  the NIH Stroke Scale (NIHSS) to objectively describe the extent of a stroke, in a language universal to all physicians, particularly our neurology colleagues.
• This validated tool consists of 15 items and the scale ranges from 0-42.  The higher the number, the worst the stroke.
• The NIHSS does not have to be memorized, but rather accessible for reference when needed.
• Studies have validated an abbreviated, 5-item NIHSS that has the same predictive performance as the 15-item scale.  This scale ranges from 0-16.
• While this abbreviated scale was created primarily for use in the prehospital setting, it can certainly be performed in the ED prior to rushing the patient off the CT for a head scan, in order to provide your neurologist with some objective information in a timely fashion.
• The NIHSS-5 assesses the following functions, in decreasing order of importance in terms of prognosis:

              --  motor function (right leg)

              --  motor function (left leg)

              --  gaze

              --  visual fields

              --  language

Ventilator Therapy for ED Patients with ARDS

• As we manage critically ill patients for longer periods of time, it is likely that many of us will manage patients who develop ARDS
• Current mortality for patients with ARDS ranges from 30-40%
• ED treatment for patients with ARDS includes treating the inciting event, supportive critical care, and ventilator management
• Current ventilator management in patients with ARDS includes:
  • avoiding alveolar overdistention (tidal volumes of 6 ml/kg)
  • maintaining F_iO₂ < 60% (mitigates oxygen toxicitty)
  • PEEP to prevent alveolar derecruitment (levels of 10-15 cm H₂O)
  • permissive hypercapnea

Reversal of Warfarin

Reversal of Warfarin can be accomplished by administering any of the following:

• Fresh Frozen Plasma (traditional reversal agent)
• Vitamin K (po, sub q, or IV)
• Prothrombin Complex Concentrates (PCC)-not yet available for use in the US (yet)

A few pearls:

• It doesn't take many units of FFP to lower someone's INR
• Don't forget volume considerations if you use FFP
• Vit K is pretty well tolerated but some patients will have an allergic reaction (more common with IV administration)
• These medications in general will be used for life-threatening bleeding (GI, CNS bleeds, retroperitoneal bleeds, etc)
• Prothrombin Complex Concentrates-rich in factors 2,7,9, and 10...perfect drug since Warfarin depletes these factors
• PCC associated with some increased thrombosis

Syncope patients are often misdiagnosed as having a seizure. Some factors favoring true syncope:
1. Preceding nausea or diaphoreses
2. Oriented (not confused) upon waking (no post-ictal period).
3. Age > 45
4. Prolonged sitting or standing before episode
5. History of CHF or CAD

Factors favoring seizures:
1. History of seizure disorder
2. Tongue biting
3. Confusion upon waking
4. Loss of consciousness > 5 min
5. Age < 45
6. Preceding aura
7. Observed unusual posturing, jerking, or head turning during episode

Management of Felons

• An abscess of distal finger that involves the pulp. 
• A difficult infection to treat due to fibrous septa that divide the pulp into multiple small compartments. 
• These septa run from the periosteum to the skin increasing the risk of osteomyelitis
• Patients typically present with a lot of pain, redness, and swelling.
• Typically triggered by a puncture wound (i.e.: splinter)
• Incision and Drainage can result in a:
  
  • anesthetic finger tip
  • unstable finger pad
  • neuroma
• If you are going to drain one it is recommended that you do a volar longitudinal incision down the middle of the finger pad or a high lateral incision. 
• The high lateral incision should be at about 5 mm below the nail plate border. This distance should allow for avoiding the more volar neurovascular structures.

For good photos of the incision technique please visit the reference article listed.

Clark, DC. Common Acute Hand Infections. Am Fam Physician 2003;68:2167-76

With the cooler weather on us all our favorite viral infections will start to appear.  Included in this is the "slapped - cheek disease" Erythema infectiosum. 

Erythema Infectiosum

• An acute viral illness caused by parvovirus B-19
• Usually is seen in the winter and spring months
• Presents with mild fever, itching, headache, and arthralgias
• Usually have an erythematous, erysipeloid rash on the cheeks (slapped look) and a reticular rash (lace-like) on the arms
• No test are needed
• Management is supportive
• Children with chronic hemolytic anemias can develop an aplastic crisis from this infection

 Olanzapine (Zyprexa)

This is an atypical antipsychotic that gained popularity because it caused less sedation and fewer extrapyramidal effects. However, there are many other adverse effects that need to be emphasized. Some of these may contribute to a patient's condition in the ED:

• Hyperglycemia: has been reported to even cause hyperglycemic hyperosmolar nonketotic coma as well as DKA in patients that were not diabetic prior to initiation of olanzapine.
• Anticholinergic: one of the most anticholinergic antipsychotics, watch for polypharmacy. Perhaps the patients urinary retention and mild confusion is due to the many anticholinergic medications the patient is taking.
• Serotonin Syndrome: again a problem with polypharmacy and in overdose.

• There is mounting evidence in favor of effectively treating migraine headaches with antiemetic dopamine antagonists such as metoclopramide (Reglan) and prochlorperazine (Compazine) as primary parenteral management.

• Diphenhydramine (Benadryl) can be administered simultaneously with such agents to prevent akathisia and dystonic reactions.

• Apart from the prophylactic effects of diphenhydramine, it may also play a synergistic role is actually treating the symptoms.

• A recent study (Friedman, et al) showed no significant difference in the efficacy or adverse events of treating migraine with 20 mg of metoclopramide plus 25 mg of diphenhydramine versus 10 mg of prochlorperazine plus 25 mg of diphenhydramine, although there was an insignificant trend in favor of prochlorperazine lowering the pain score to a greater degree.

• Note that the 20 mg dose of metoclopramide is higher than what is traditionally used in most emergency departments, but escalating the dose of up to 20 mg over a few hours may be more efficacious (the slower the administration and the simultaneous use of diphenhydramine decreases risk of dystonic reactions).

 Influenza and the Critically Ill

• It is that time of year again to be vigilant for cases of influenza
• Influenza is not benign and causes > 40,000 deaths per year and is the 7th leading cause of death in the US
• In the critically ill, the most severe disease occurs in patients > 65 and those with underlying cardiopulmonary disease
• Critically ill patients with influenza can present with fever, cough, bilateral interstitial infiltrates, hypoxemia, and leukopenia
• Other serious complications include myocarditis, encephalitis, and Reye syndrome
• Amantadine and rimantadine should no longer be used, as the resistance has risen to > 90% in some populations
• Oseltamivir (PO) and zanamivir (powder/inhalation) are the approved neuraminidase inhibitors; both decrease the severity and duration of illness; should be given as early as possible, preferably within 36 hours

Anticoagulation with Heparin-How to Reverse?

So you just started Heparin on that ACS patient? Just bolused the patient in room 12 with the large PE with a slug of Heparin? The nurse tells you that one of them just vomited blood and the other just had a large bloody bowel movement. What to do, oh, what to do?

How to reverse Heparin...use Protamine:

• Protamine is obtained from the sperm of salmon and other species of fish....glad you know that now?
• Given IV, it binds to Heparin (Unfractionated Heparin) and inactivates it
• Administer Protamine (IV) at a dose of 1 mg for every 100 Units of Heparin given within the last four hours. Max dose 50 mg of Protamine. May give more than 50 mg, but use caution as may lead to bleeding
• If the dose of Protamine is exceeded, patients may bleed. Protamine is actually an anticoagulant. 
• Give slowly over 10 minutes as may cause anaphylactoid reaction
• Can use to reverse LMWH as well: 1mg Protamine per 1 mg of LMWH (Lovenox)

Amiodarone-induced hypothyroidism is well-reported and should be considered anytime a patient that chronically takes amiodarone presents with hypothyroid symptoms, including decompensated CHF, decreased mental status, or myxedema coma (e.g. bradycardia, hypotension, hypothermia). 

Other drugs that have been implicated in producing hypothyroidism include lithium, iodine, iodinated contrast, and sulfonamides.

Bisphenol A (BPA) is found in epoxy resins that line common food and beverage materials. There has been concern that this compound, like phthalates, may be causing harm through chronic low exposure. An epidemiologic study was performed and published in JAMA that has raised this question. Amazingly, the study did find that:

• Higher urinary BPA levels correlated with an increase incidence of: NIDDM, CAD and elevated liver enzymes
• Mechanism may be an estrogen effect, disruption of Beta-islet cell function and even obesity promoting effects
• Study was strictly epidemiologic but raises a serious public health concern that you will see in the news more

-- Tourette Syndrome (TS) is an inherited neurological disorder characterized by repetitive involuntary movements and uncontrollable vocal sounds called tics.
-- Underlying defect is unknown; however, research suggests that it could be caused by abnormalities in serotonin and dopamine activity within the basal ganglia.
-- Associated behavioral problems include OCD, ADHD, anxiety, and depression.
 

Diagnostic criteria:

Can You Rely on Your Clinical Impression to Exclude SBP?

• SBP is an important can't miss diagnosis, as the mortality rate even for treated patients is approximately 20%
• The incidence of SBP ranges from 2.5% (clinic setting) to 12% of all patients admitted with decompensated cirrhosis
• SBP is diagnosed by a neutrophil count > 250 or a positive ascitic fluid culture obtained via paracentesis

• Can our clinical impression exclude SBP without performing a paracentesis? Unfortunately, the answer is NO.
• Sensitivity of physician clinical impression is just about 75%, with a specificity of 34%
• Fever is uncommon in patients with SBP (sensitivity as low as 17%)
• Take Home Point: only a diagnostic paracentesis can reliably exclude SBP in patients admitted for decompensated cirrhosis

Cerebral Venous Sinus Thrombosis (CVST)

An uncommon but very serious entity that leads to three distinct types of presentations:

• Headache
• Seizures
• Stroke

Caused by thrombosis of one of the intracerebral venous sinuses (most commonly the transverse sinus) The major risk factor is hypercoagulable disease. May be the underlying cause of a majority of cases of idiopathic intracranial hypertension.

When to suspect:

• Headache with negative CT, negative LP, but high opening pressure
• In any patient with new onset idiopathic intracranial hypertension (i.e. pseudotumor cerebri). Can't be formally diagnosed without a negative MRI.
• Stroke syndrome that doesn't quite fit. May see bilateral infarcts in the posterior regions. These are actually venous infarcts secondary to the sinus thrombosis.

Diagnosis:

• Just like a lot of other things in medicine, "If you don't think about it, you can't diagnose it."
• 1 in 3 head CT scans will be normal
• MRI with MRV (venous phase) is the diagnostic standard

Treat:

• Anticoagulation with heparin then warfarin

An estimated 20-30% of patients with ACS end up having no identifiable culprit lesion on angiography. Almost half of these patients have inducible coronary spasm. Although these patients have a good outcome, they also have a tendency to return to the hospital for frequent re-evaluations. Evaluation for and treatment of spasm can improve the quality of life for these patients and also to decrease re-visits.

When patients with reports of "clean" coronaries return to the ED with a concerning presentation for ACS, one of the considerations should be coronary spasm. Consider prompting the primary care physician or admitting team to look into this possibility, as it may result in a reduction in recurrent ED visits.

Severe Hypothyroidism or Myxedema Coma

• Mortality rate has been as high as 80% now 15-20% with aggressive treatment
• Some common symptoms are:
  • Constipation
  • Depression
  • Lethargy
  • Dry, Brittle hair or Alopecia
  • Weight Gain
  • Cold Intolerance
  • Weight Gain
• Treatment consists of:
  • Rule out aggravating cause (i.e.: infection)
  • Start IV levothyroxine dosing
    • Initial dose 400-500 mcg (Helps to saturate the thyroid receptors)
    • Daily dose 100 mcg/day
  • Consider starting Dexamethasone or doing a Cortisol stimulation test
    • Patients may also have adrenal insufficiency from primary pituitary failure or may have secondary adrenal suppression due to the severe hypothyroidism.  If dexamethasone is not provided they may develop severe adrenal insufficiency once you kick start their metabolism.

Pediatric Discitis is an intervertebral disc infection due to hematogenous spread to vascular channels in cartilage that disappear later in life.  In 1/3 of patients it is caused by S. aureus.

Presenting Features

• age <2.5 years (75%) 
• Refuse or difficult to walk  (56%)
• Back/neck pain (25-45%) ( 100%>3years)
• Hx of fever (28-47%)
• lumbaosacral area (78-82%)
• Mean ESR 39-42
• WBC> 10,500 (50%)
• Abnormal MRI 90-100 %

Management is to exclude more severe disease (osteomylelitis,abscess, tumor) and antibiotic use is debatable.  Remember children this age rarely complain of back pain. 

Clinical Manifestations in relation to lead level in children:

• > 70 - 100 mcg/dL: Encephalopathy, increased ICP, anemia, vomiting
• 50 - 70 mcg/dL: Irritable, difficult child, abdominal pain, anorexia
• >10 mcg/dL: often asymptomatic, may develop impaired cognition, behavior, impaired fine-motor coordination, hearing and growth

Tension gastrothorax?

• Tension gastrothorax is a life threatening condition characterized by herniation of the stomach through a defect in the diaphragm with compression of the mediastinal contents
• Although many cases occur in pediatric patients (secondary to congenital defects), adults with a history of diaphragmatic injury are at risk (also patients with a type III or IV hiatal hernia)
• The clinical presentation is the same as a tension pneumothorax - hypotension, tachycardia, hypoxia, JVD, and decreased breath sounds
• CXR appearance can be very similar to tension pneumothorax, however, the treatment is substantially different
• Needle decompression and tube thoracostomy are contraindicated, as this may cause visceral perforation
• The treatment of choice is NGT (or OGT) decompression followed by surgical repair

 Does Hypertension (elevated BP) Cause Headache?

This is an age old question that many of us have struggled with in the ED for many years...

Other questions include: Does elevated BP cause headaches? Do we need to scan hypertensive patients with headache just because they have a headache? At what level of BP does the BP actually cause headache? 

A few quick pearls:

• Although incredibly high BPs (diastolics above 130 mm Hg) have been correlated with headache, the general concensus is that hypertension doesn't really cause headaches. 
• At really high blood pressures (again, diastolic BP > 130-140), cerebral autoregulation breaks down and may lead to cerebral edema and headache...hypertensive encephalopathy.
• Elevated systolic BP may actually be protective for developing headaches
• CT scanning the hypertensive patient with a headache is not warranted a lot of the time, unless the patient has a neuro deficit, or if the headache was acute onset or associated with other findings of hypertensive encephalopathy.
• Patients with HTN are as likely to have a headache in the ED as non-hypertensive patients

Severe emotional stress is well-reported to produce an unusual transient cardiomyopathy that mimics cardiac ischemia or infarction on ECG as well as biomarker testing. On angiography, the coronaries are often clean. The ventriculogram takes on an apical or mid-ventricular ballooning appearance due to akinesis. In the ED, these patients will look just like a real thrombosis-related case of ACS and they often develop cardiogenic shock. Unlike true AMI-related cardiogenic shock, these patients have an excellent prognosis...if treated aggressively early-on with supportive therapy (e.g. pressors).

Intracranial catastrophes, such as hemorrhage, ischemic stroke, and head trauma; and severe medical illnesses, such as sepsis, pheochromocytoma, and catecholamine-excess states, are also reported to produce a similar syndrome of LV dysfunction.

The takeaway points: (1) severe emotional stress can be deadly...be wary of diagnosing "anxiety" or "panic attack" without checking an ECG; (2) check an ECG early in the course of any patients with the above conditions that look sick; (3) if the ECG shows signs of severe ischemia, aggressive treatment can be life-saving.

[ref: Bybee KA, Prasad A. Stress-related cardiomyopathy syndromes. Circulation 2008;118;397-409.]

Mallet Finger:

A common injury resulting in a tear or avulsion of the extensor digitorium tendon inserting into  the base of the distal phalanx.  Occurs due to hyperflexion of the finger usually as of a esult of it getting jammed on a ball while playing sports.  Most can be treated non-surgically.

The distal phalanx must be kept in full extension for 6 to 8 weeks. This is one of the few times that the finger should not be splinted in the position of function.

Make sure that patient is informed that if they remove the splint and flex their finger the 6 to 8 week healing window will be reset to day 0.  These patients should not be doing ROM exercises and must wear the splint full time.

Popsicle or cold panniculitis is an inflammation of the subcutaneous fat after prolonged exposure to cold.  It is thought to occur more often in infants and young children because they have a higher percentage of saturated fatty acids than older children and adults.  Pediatric patients may present to you to be evaluated/ruled out for abuse by social workers, schools, or police and if you have the correct history it is easy to dispo quickly.

Clinical Features of Popsicle Panniculitis

• Absence of systemic signs
• Minimal pain, with or without
• Skin is red to purplish, indurated, may have discrete nodules or plaques
• perioral location for popsicles, but may occur at any other area of skin exposure
• resolves in 2-3 weeks without scarring
• hyperpigmentation may persist
• arises within hours to to 1-2 days after exposure to a cold object

Several antihypertensive agents raise intracranial pressure. Normal cerebral blood flow (CBF) is constant within normal cerebral perfusion pressure (CPP) ranges, recalling that CPP=MAP-ICP.

If CPP is outside the range in which autoregulation occurs, e.g. due to a structural lesion, ischemic stroke, or head trauma, CBF decreases and can adversely affect the patient.

• Nitroprusside
  • Vasodilates both cerebral arteries and veins, increasing ICP
  • Inhibits the normal vasoconstrictive response to hypocapnia
• Nitroglycerin
  • Causes cerebral venodilation, increasing ICP
  • Impairs vasodilatory response to hypercapnia
• Hydralazine (varying effects)
  • Vasodilates cerebral arteries > cerebral veins
  • Impairs cerebral autoregulation
• Nicardipine
  • Other calcium channel blockers increase ICP by vasodilating arteries
  • Has been used to treat vasospasm in SAH
  • Increases cerebral blood flow in patients with SAH and acute stroke

In patients with ischemic stroke or intracerebral pathology, labetalol or esmolol may be used to lower blood pressure without raising ICP. Nicardipine is recommended for use in patients with ischemic stroke or SAH but not in patients with brain injury

If the patient has NO structural abnormalities, but has hypertensive encephalopathy, nitroglycerin, nitroprusside, labetalol, esmolol, or nicardipine may be used.

• Encephalomalacia, also known as cerebromalacia, is a softening of brain tissue that results from ischemia or inflammation, most typically due to vascular insufficiency or degenerative changes.

• On Brain CT, it appears as a darkened area and can be confused for cerebral edema due to acute ischemia (i.e stroke).

• Unlike edema, encephalomalacia on CT is often accompanied by:

                    ---  well defined, circular vacuoles

                    ---  presence of good gray-white matter differentiation in surrounding areas

                    ---  a lack of significant effacement or lost of sulcus definition

                    ---  a history of prior stroke or head injury

Subcutaneous Insulin in the Critically Ill

• Although intensive insulin therapy in the critically ill remains controversial and a matter of much debate, hyperglycemia is common in the critically ill ED patient
• Hyperglycemia is associated with worse outcomes in this patient population
• When treating hyperglycemia in the critically ill ED patient, use caution with subcutaneous insulin
• Absoprtion of insulin administered subcutaneously is slow, erratic, and highly variable often due to poor perfusion, hypotension, and/or vasopressor therapy
• In these patients, IV insulin is a better route of administration and leads to more reliable control of hyperglycemia
• Recall that the onset of action of insulin given IV is 10 - 30 minutes, with a duration of action of about 1 hour

Avoidable Pitfalls in Managing the Hypertensive Patient

We all see very hypertensive patients on almost every shift. Dr. Winters has an earlier pearl related to pitfalls in treating patients with hypertensive encephalopathy, but I thought it was time to reiterate just a few points.

• No evidence to date has ever shown a benefit to acutely lowering someone's BP in the ED prior to discharge
• Probably the best thing you can do for the patient with out of control BP is to arrange (and make sure they have) followup for the next day or two after discharge
• In patients with severe HTN (eg. admitted patients with pressure to high to go to their inpatient bed), avoid agents like IV Hydralazine. This agent is pretty reliable in being completely unpredictable when it comes to BP response. Some will really bottom out their BPs.
• Avoid Clonidine unless the patient is on it and stopped taking it recently (rebound HTN). May worsen someone's already crappy mental status.
• If a patient is being admitted, say to a unit or step down unit, don't bother titrating oral agents for people with pressures > 240/130 mm Hg or so. Consider a drip-oral agents may "stack" and take effect, thus lowering someones BP way lower than you wanted.
• Don't treat the number, treat the patient.

 A normal ECG should not be a huge source of relief when evaluating patients with possible or confirmed myocardial infarction. 8% of acute myocardial infarctions have a completely normal ECG at the time of presentation, and these patients have a 5.7% in-hospital mortality. Serial electrocardiography can certainly improve the yield of electrocardiography but does not rule out AMI with 100% accuracy.

Like most tests in medicine, the ECG is very useful at ruling in disease, but it is limited at ruling out disease.

[The Prognostic Value of a Normal or Non-specific Initial ECG in AMI. JAMA 2001.]
 

Paracentesis Part II- Ascites Fluid Analysis:

See last weeks procedure pearl for some hints on doing a paracentesis..

Now that you have the fluid what should you send it for:

• Cell Count
• Gram Stain and Culture
• Amylase (normal value is half serum)
• Albumin
• Consider cytology if  cancer is a consideration

Now for the analysis:

• WBC Count >250 PMNs generally accepted as consistent with infection.  Especially if there is more than 70% PMNs which is the upper limit of normal. SAAG (Serum - Ascites Albumin Gradient) an easy calculation to differentiate what the cause of the ascites might be from:
  • Subtract the patient's ascites albumin from the serum albumin (Serum Albumin - Ascites Albumin = SAAG)
  • SAAG > 1.1 mg/dL(Due to items that increase portal pressures)
    • Cirrhosis
    • Alcoholic Hepatitis
    • Cardiac Ascites
    • Hepatic Failure
    • Budd-Chiari Syndrome
    • Portal Vein Thrombosis
    • Myexdema
    • Others
  • SAAG < 1.1 mg/dl (due to intraabdominal forces causing increased oncotic pressure)
    • Tuberculosis Peritonitis
    • Pancreatitic Ascites (typically while have elevated amylase in ascitic fluid)
    • Bowel Obstruction
    • Nephrotic Syndrome
    • Biliary Ascites
    • others

** Corrected definition of SAAG as it was initially reversed.  Thanks to Dr. McCurdy on his proof reading.

 Melamine

• In case you thought the chinese only sent their toxin filled products to the USA, a massive scandal has been occurring with their milk.
• Adding melamine to their milk, companies were able to get falsely elevated readings of protein which is measured by the government to make sure the milk was not watered down.
• 53,000 illnesses, over 12,000 hospitilizations and at least 4 infant deaths have been attributed to their milk supply - 20% of China's milk supply is thought to be contaminated
• Melamine or melamine resin is used to make plastics and involved in other polymeric reactions.
• Toxicity involves the creation of kidney stones - imagine the pain in these poor children
• These children died from renal failure from multiple kidney stones.
• Check the link below to the news article

• Acceleration, deceleration, and rotational forces cause diffuse axonal injury (DAI).
• It is characterized by widespread shearing and retraction of axons during traumatic brain injury (TBI).
• DAI often results in coma and is associated with poor prognosis.
• In addition to cortical white matter injury, it often also involves the corpus callosum, basal ganglia, brainstem, and cerebellum.
   

AIDS: coming to a critically ill patient in your ED

• Acute intestinal distress syndrome (AIDS) is a recently coined term used in the continuum of intraabdominal hypertension (IAH) to abdominal compartment syndrome (ACS)
• In previous pearls we have discussed the importance of IAH in the critically ill and how to measure intraabdominal pressure (IAP)
• Recall that IAH is defined as a sustained elevation of IAP > 12 mmHg
• The focus of attention is shifting to "secondary ACS" - it is highly prevalent in the critically ill and is independently associated with increased mortality
• Sepsis is a cause of secondary ACS and is the most likely condition we will encounter in our critically ill patient population
• Current recommendations suggest that IAP be measured daily in patients at risk for IAH (i.e. the septic ED patient)

So, how good is a screening CXR for aortic dissection?

• Classic CXR finding is a wide mediastinum
• Pooled literature shows that the overall sensitivity of a CXR is about 67-70% for aortic dissection (even if upright, or PA and Lateral)
• Most authorities agree that a screening CXR alone is not sufficient to r/o aortic dissection

17-18% of cases of syncope are attributable to dysrhythmias.
The best predictors of dysrhythmias in these patients are:
1. abnormal ECG (odds ratio 8.1)
2. history of CHF (odds ratio  5.3)
3. age > 65 (odds ratio 5.4)

[reference: Sarasin FP, et al. A risk score to predict arrhythmias in patients with unexplained syncope. Acad Emerg Med 2003.]

Paracentesis:

Since we have covered so many other procedures I though I would include paracentesis for completion.

A diagnostic paracentesis (typically 30-60 ml)  is indicated to:

• Determine etiology of new ascites (transudate vs exudate, cancer, infection)
• Rule out spontaneous bacterial peritionitis...(suspect this in any patient with a history of ascites that has fever, mental status changes, or diffuse abdominal pain)

A therapeutic paracentesis (large volume >1L) is indicated in the emergency department for:

• Respiratory distress from abdominal distension
• Abdominal compartment syndrome.  See Dr. Winters Pearl

Remember large volume paracentesis can result in profound fluid shifts and subsequent hypotension.

Absolute Contraindications to paracentesis include:  Acute abdomen requiring surgery

Relative contraindications are:

• Platelets <20,000
• INR > 2
• Pregnancy
• h/o adhesions
• abdominal wall cellulitis (just don't stick the needle through the cellulitis)
• Distended bowel or bladder

To view a video on how to do a paracentesis please visit the New England Journal of Medicine http://content.nejm.org/cgi/content/short/355/19/e21

Next I will address how to interpret the paracentesis fluid results.

Oxycodone v. Codeine for Fracture Pain Management in Children

• When choosing an oral narcotic to give a child for fracture analgesia oxycodone is a better choice than codeine. 
• In this study children were randomized to recieve equianalgesic oral doses of either oxycodone (0.2 mg/kg, max 15 mg) or codeine (2mg/kg, max 120 mg) for forearm fractures
• Children given oxycodone reported a pain score significantly lower than children given codeine
• And children given oxycodone had less itching than those given codeine

 Cheese Heroin: a slang term for the combination of heroin with an over-the-counter antihistamine

• The two are combined and forms a cheesy like powder that is different from pure heroin
• A string of deaths were reported between 2005-2007 in Texas, many adolscents
• This concoction is more often insufflated than smoked or injected
• Combines opioid effect with the anticholinergic confusion and hallucinations
• Scorpion was a heroin that was combined with scopolamine that had similiar effect

Treatment

• Find the anticholinergic toxidrome, place the foley and supportive care are mainstays
• Consider administration of physostigmine 1mg IV slowly over 2-5 minutes (call toxicologist)
• The anticholinergic effects will linger much longer than the heroin effects ( <1hr)

tPA should NOT be used to treat ischemic stroke in the following instances:

• Platelet count < 100,000
• INR > 1.7 or PT > 15
• Heparin administration within past 48 hours with subsequent PTT above upper limits of normal

Health care-associated pneumonia

• Health care-associated pneumonia (HCAP) is a distinct entity
• HCAP includes any patient with pneumonia and 1 or more of the following:
  • hospitalization for 2 or more days in an acute care facility within the preceeding 90 days
  • nursing home patients
  • patients of long-term care facilities
  • patients who attend a hospital or hemodialysis clinic
  • patients who received IV antibiotics, chemotherapy, or wound care within 30 days of infection
• Data indicate that the mortality for HCAP is higher than CAP
• The most common organisms in HCAP include S.aureus, P.aeruginosa, Klebsiella species, Haemophilus species, and Escherichia species
• An initial recommended antibiotic regimen includes a combination of an antipseudomonal cephalosporin plus a fluoroquinolone plus an agent active against MRSA

Key Cardiovascular complications of cocaine:

• Myocardial ischemia and infarction
• Myocarditis and cardiomyopathy
• Aortic dissection
• Vessel thrombosis
• Stroke (usually hemorrhagic) 
• Visceral ischemia

Pearls:

• Cocaine and abdominal pain=mesenteric ischemia, hemoperitoneum (described)
• Cocaine and chest pain=MI, aortic dissection
• Cocaine and extremity pain=arterial thrombosis, aortic dissection
• ~ 6% of cocaine chest pain patients rule in for MI

 HIV positive patients are at increased risk of premature