Wednesday Lectures, 5/27/2015

TTHM 12.4 (5/27) PDR

 

10a ~ PDR (Paolo)

*#FOAM Apneic Oxygenation, Levittan & Weingard podcasts, nasal cannula during apnea

Worst case scenario, probably does nothing… RCT facemask plus/minus apneic O2 during RSI

No statistical significant difference.  Be skeptical of podcasts too…

*Abx for CAP, Ceftri/Azith… or Levaquin/Moxi… Quinolones seem to develop resistance quick.   Cef v Cef/Azith v Levo… all did similar.  Noninferior.

*Antibiotics for fingertip amputations, zero infections across groups, no benefit?

*Lactate… corresponds to hemorrhagic shock, but also increased c EtOH consumption.

*CT in SAH pretty darn good for NPV (despite bias with low prevalence), LP may not be necessary for this context…

 

11a ~ PSQ (Goldberger/Adcock/Shaw)

 

1p ~ Journal Club (Kolb)

*Therapeutic Hypothermia in Peds Cardiac Arrest OOH

NO STATISTICALLY SIGNIFICANT DIFFERENCE (MILD TREND TOWARD BENEFIT)

*Antibiotics for CAP

NO STATISTICALLY SIGNIFICANT DIFFERENCE Cef v Cef/Azith v FQ…

 

2p ~ Cardiovascular Toxins (Stork)

*Digoxin NaK~ATPase inhibition increases intracellular Calcium… 20mg can be fatal! Visual “Halos” toxic effect… Potassium >5 poor prognostic! All K >5.5 died in toxicity study!  Most common arrhythmia is freq PVCs… bidirectional VTach (bigeminy) pathognomonic… prolonged PR & “Salvadore Dali Mustache”.  Maximum Therapeutic Digitalis level up to 2, but dangerous Dig level >20… or K > 5.  Digibind give 10 vials for unknown qty (both adults & kids). Do NOT give Calcium dt “Stone Heart” potential phenomenon?…

*Verapamil OD: Bradycardia Hypotension (c BB CCB aBlock Dig)…

CCB OD tend to stay awake & have high glucose (insulin release inhibited)…

Sustained release forms may have delayed onset… Give Calcium for CCB OD, consider charcoal, consider whole bowel irrigation (early only), consider lipid emulsion last resort! (fat emulsion ~ TPN… One of the most common Tox bad outcomes.

*BB OD ~ remember High Dose Insulin Euglycemia!

*Clonidine & alpha blockers try naloxone high dose, & supportive care!

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Program Director’s Rounds

The Effect of Ethanol on Lactate and Base Deficit as Predictors of Morbidity and Mortality in Trauma
doi:10.1016/j.ajem.2015.01.030
http://www.sciencedirect.com/science/article/pii/S0735675715000327
[Through Upstate Library]

The use of prophylactic antibiotics in treatment of fingertip amputation: a randomized prospective trial
doi:10.1016/j.ajem.2015.02.002
http://www.sciencedirect.com/science/article/pii/S0735675715000625
[Through Upstate Library]

CT within 6 hours of headache onset to rule out subarachnoid hemorrhage in nonacademic hospitals
Neurology. 2015 May 12;84(19):1927-32.
doi: 10.1212/WNL.0000000000001562.
Epub 2015 Apr 10.
http://pubmed.gov/25862794
[Through Upstate Library]

High-flow nasal cannula oxygen during endotracheal intubation in hypoxemic patients: a randomized controlled clinical trial
Intensive Care Med. 2015 Apr 14. [Epub ahead of print]
http://pubmed.gov/25869405
[Through Upstate Library]

Antibiotic Treatment Strategies forCommunity-Acquired Pneumonia in Adults
N Engl J Med. 2015 Apr 2;372(14):1312-23.
doi: 10.1056/NEJMoa1406330.
http://pubmed.gov/25830421
[Through Upstate Library]

Trauma Patients: Health Insurance Reform Is Only the Beginning.
JAMA Surg. 2015 May 6.
doi: 10.1001/jamasurg.2014.2470. [Epub ahead of print]
http://pubmed.gov/25945655
[Through Upstate Library]

Wednesday Lectures, 05/13/2015, “Weakness” Day

TTHM 12.2 “Weakness” Day (5/13/15)  Tint. Ch. 53, 166, 167, pp.1545, 1546

 

10a ~ Multiple Sclerosis (Kolb)

Treated c high dose steroids, occasionally plasmapheresis.

…Rudolf Virchow discovered myelin, taught Kussmaul, Osler…

Charcot’s Neurologic Triad: Nystagmus, Intention Tremor, Staccato Speech (NOT charcot’s triad for cholangitis: fever, jaundice, RUQ pain)

Affects more women than men typically onset 15 to 45 yo.

Multiple types: Relapsing, Remitting, Secondary Progressive, Primary Progressive, Progressive Relapsing.  Etiology somewhat uncertain, less incidence closer to equator.

Lhermitte’s sign: shooting electrical pain c neck flexion (“barber chair phenomenon”)

Optic Neuritis, scotomas, discolored vision

internuclear ophthalmoplegia (delayed abduction)

MS flares get high dose steroids.

*Case: MS Flare c Neurogenic Flash Pulmonary Edema

still treat c high dose steroids… MS flares also highly associated c UTI…

Dx made by MR, c LP sometimes used for exclusion of competing Dxs…

Uhthoff’s phenomenon

 

1030a ~ Movement Disorders (Pipas)

Definitions & Parkinsonism…

Tremor ~ rhythmic involuntary movements related to voluntary movements (rest, intent, posture)

(Alcohol withdrawal can have multiple involuntary movements)

Myoclonus ~ hiccoughs, nocturnal myoclonus, sudden rapid twitching, asterixis (can be found c etomidate)

Asterixis ~ within myoclonus, liver disease…

Chorea ~ Sydenham’s c Strep rheumatic heart Dsx, Huntington’s, Wilson’s Dsx, Levodopa…

Athetosis ~ slow writhing movements c antipsychotics, tardive dyskinesia…blinking, grimacing, tongue movements… can occur c long term Reglan use…

Hemiballism ~ unilateral Chorea, violent movements of proximal limb muscles

Dystonia ~ sustained abnormal postures

Torticollis ~ neck muscle spasm uncomfortable & anxiety producing

Akathisia ~ restlessness & agitation, shuffling…

Tics ~ frequent, often in childhood, repetitive coordinated movements, suppression causes anxiety…

PARKINSON’s ~ ?genetic predisposition ~ damage to dopamine pathways in substantia nigra… Resting pill rolling tremor, cogwheel rigidity, masked facies & bradykinesia, festinating shuffling gait c postural instability.  80% idiopathic.  Benztropine for tremor, & Sinemet (carbidopa levodopa).  OD of meds can have schizophrenic ~ like presentations, AMS…

Take advantage of YouTube Videos for characteristic movements!

 

11a ~ Small Groups (Lavoie, Farber)

*Radial nerve Palsy ~ Saturday Night Palsy, Honeymoon Palsy (snuffbox sensation, wrist extension) …Posterior Interosseous Nerve ~ Radial Nn branch, behind lateral epicondyle ~ tennis elbow

*Median Nerve ~ Phalens & Tinels signs for Carpal Tunnel Impingement (pad of 2nd digit, wrist flexion) …Anterior Interosseous Nerve ~ “ok” sign, thumb Adductor (can be isolated injury)

*Ulnar Neuropathy ~ Cyclists/Biker’s Palsy, affects Adducts fingers, “funny bone”, Guyon’s canal (sensory pad of 5th digit, spread fingers)

 

12p HTN & HTN Emergencies (Kajla) ~ How high is BP too high to send home?

No specific #? All clinical judgment?

Per ACEP policy:  140 to 159 followup… 160 to 179 followup… 180 to 209 HTN “Urgency” contact PCP & consider 2 drug therapy.  >210 too high, strongly consider initiating 2 drug therapy! & if symptomatic, obviously workup end organ damage pathology!

 

Case Report: Emphysematous Cystitis (rare, found in elderly women c DM, thought to be related to bacterial fermentation process)

 

1230 ~ Jr/Sr Sessions (Prasad/Rodriguez)

*Case1) MMWR (Sept 2006) Dermacentor Adersoni (Rocky Mountain Wood Tick) Tick Paralysis dt toxin in tick saliva works on ACh receptor in motor neuron endplate. 6yo girl intubated!

*Case2) Trendelenburg Gait, Back Pain & weakness… LEMS presynaptic weakness vs Myasthenia Gravis (often c ocular muscle weakness)… often associated c cancer, but cancer may not be detected.  LEMS over age 50, especially smokers, often associated c lungCA.

*Case3) 29M sudden paralysis, K 1.6 ~ Mobitz 1 block.  Periodic Paralysis (Familial Hypokalemic).  IV Potassium c dramatic symptomatic improvement! Occurs dt rapid intracellular shift.  Often occurs concurrent c hyperthyroid, autosomal dominant condition.  Treat c K supplementation, acetazolamide, spironolactone…

*Case4) 17M weak, difficulty swallowing… no ocular problems, no neck or backache, PMHx 1 month prior c URI, Bell’s palsy & 9th/10th cranial nn. problems c swallowing… Systemic leukocytosis of 25K!  GBS!!! Can be dt B vitamin deficiencies, Toxic, Metabolic, Postinfectious, RA, SLE, hereditary/Idiopathic…  LP albuminocytologic dissociation…

 

130p ~ GBS (Joslin) Life in the Fast Lane

aka AIDP (Acute Inflammatory Demyelinating Polyneuropathy)

*Case1) Transverse Myelitis started with difficulty urinating

*Case2) GBS sp needlestick exposure

 

2p ~ Myelitis (MacConaghy)

Which one is transverse myelitis? Sensory deficits most common, often bladder, may be asymmetric, specific level deficits!

*Case1) 70F proximal muscles & urination weak, no incontinence, some hyperreflexia & POS babinski, positive romberg, but good cerebellar coordination.

*Case2) 51F midback pain, ascending numbness & weakness in legs, went to chiropractor, can’t walk, hyperreflexic, good rectal tone.

*Case3) 30M c 6 days numbness below the neck, difficulty c hot cold discrimination, & can’t feel pain in feet, sensory is only deficit!

“Transverse” myelitis refers to bandlike sensory deficit!

Criteria for diagnosis: ro other causes, *clearly defined sensory level!, analogous to spinal cord compression symptoms, sensory motor or autonomic dysfunction attributable to spinal cord!

Most have neck or back pain & recent illness.

(ADEM ~like MS in a kid with fever & encephalitis)

MRI with contrast is needed for diagnosis.  LP may be needed to exclude DDx…

Labs ~CRP/ESR, lyme, TB, fungal, B12, ANA things to consider… NMO~Ig new test…

Treatment c Steroid & Abx (high dose Decadron or Solumedrol), consider plasma exchange…

Prognosis 1/3’s: 1/3 complete recovery, 1/3 partial recovery, 1/3 significant permanent deficits.

Case 1: Cervical Myelopathy

Case 2: Bony Metastatic disease, BRCA

Case 3: Focal Abnormality, though sensory deficits ONLY. This case 2* to MS.

 

230p ~ Myasthenia Gravis (Maley)

Autoimmune disorder ~ antibodies against ACh~Receptor (Anti~AChR Ab)

PostSynaptic, T lymphocyte role can be associated c thymic inflammation…

ED what do you need to know? DX: clinical.

Meds to AVOID?  & How to treat EXACERBATION?

Bimodal distribution of age (20s to 30s female & 60s to 80s male)

Juvenile MG Ab can cross placenta… common presenting diplopia & pstosis

Airway protection is big priority!

Tensilon Test (edrophonium)… Some meds make it worse: Cipro/Levoflox, Azith/Gentamycin…

Treat c high dose steroids.  For paralysis DO NOT USE SUX!

LEMS has LE proximal muscle weakness, often associated c small cell lungCA…

Snake venoms may cause similar symptoms c Coral snake (elapidae) & Mojave rattlesnake (crotalid, CroFab?)

 

3p ~ Bell’s Palsy (Lavoie)

Cranial Nerve VII inflammation, can be Lyme, HSV, VZV…

Most cases idiopathic, commonly treated c steroid & acyclovir for empiric & symptomatic management.  Hyperacusis often precedes, dt stapedius tensor tympani paralysis.  Loss of taste & dry mouth also common findings…  Facial “numbness” report very common dt altered proprioception, although sensation will be present on physical exam testing.

Smaller deficit, bigger problem?  Sparing of the forehead typically ~ CVA!

Bell’s can be b/L!  Eye exam c Hutchinson sign c zoster.  In endemic region, consider Lyme testing…

Eye patch or tape, eye ointment, acyclovir, steroid may have role in treatment…

Steroids help 10% of the time per Cochrane, relatively safe, NNT 11 to 12…

Antivirals no significant benefit or harm…

Imaging not routine, though MRI occasionally useful, might have falsePOS… ro CVA if necessary, i.e. atypical presentations.

Wednesday Lectures: 05/06/2015

TTHM 12.1  Electrolytes Day  (5/6/15) Tintinalli 19,20,21,137,142,225.

 

10a ~ Acid/Base (Prasad)

1) Primary Disturbance? Acidosis? Alkalosis? pH? 7.35 to 7.45?

2) Resp or Metabolic? pCO2<40? Bicarb<24?

3) Secondary Disturbance? AG? DeltaAG? (in acidosis, difference from 10…)

AGMA? MUDPILES…

4) Corrected Bicarb should be is Measured Bicarb plus DeltaAG…

Winters Formula for Metabolic Acidosis expected pCO2 should be 1.5x Bicarb plus 8!

*Mixed disorders such as ASA OD (Sepsis & LiverDsx) can cause Met Acid c Resp Alk…

 

1030 ~ Nutritional Disorders (Nicholas)

*Case 1) EtOH, lazy eye, well known…

Wernicke’s Encephalopathy, Thiamine (Folate, B12…) Thiamine is rapidly metabolized quickly as a water soluble vitamin, need regular intake!  Wernicke’s develops rapidly.  Genetic predisposition & absorption problems play a role even despite supplementation.  Magnesium is also an important cofactor.  If in doubt, hang a banana bag.  Ophthalmoplegia & nystagmus often resolve within days, Ataxia & AMS may take longer & have sequelae.  ICU stays may be indicated!

*Case 2) 3 wks N/V in 24F ~ Hyperemesis gravidarum is formal diagnosis c ketone formation.  Ketone clearance (urine check) needs dextrose metabolism in addition to IVF!

*Case 3) Skin discoloration from chronic exlax use (phenolphthaline), fixed drug eruption… Developed “Cathartic Colon” causing persistence of electrolyte disturbance.  Anorexia should be screened for concomitant psych or metabolic disorders… screen for SI risk, bulemia…

 

11a ~ Small Groups (Rodriguez, Lavoie)

*VA, old guy, weakness… EKG!!! HyperKalemia… Calcium Albuterol InsulinGlucose, Kayexalate

Theoretically be aware of Digoxin toxicity, “stone heart”, CaCl sclerosing (avoid in Peds & IO), CaGluc generally favored.  10U Insulin Regular & D50 x50cc Amp, may shift K up to ~1mEq… Albuterol can neb continuously, numerous treatments (10 to 20mg!!!), can use IV terbutaline?! …but may be ineffective if beta blocked or idiopathic inefficacy.

…Dialysis.

 

12p ~ Kai Academic Project ~ Snow on ED volumes… NEG correlation between visits/day & avg inches snowfall. ~5% effect strength.

 

1230 ~ Jr/Sr Session (Paolo, Lavoie)

Procedures… More blocks, splinting, suturing…  Ortho nomenclature: “displaced”, “angulated”, “rotated”… NYTimes ~ Maureen Dowd? “Stroke of Fate”… Dave Newman response in HuffPost… Finger angulation allowed 10, 20, 30, 40 degrees respectively until reduction needed… Fix rotational deformity for preservation of function of hand… Boxer’s Frx c Ulnar Gutter splints, 20* & 90* intrinsic plus positioning, or radial gutter splint c thumb hole.  Carpals: remember 3 curves: radius, lunoscaphoid, capitate. Scaphoid Frx ~ thumb spica splint.

*Weber ankle frxs: from A to C: higher fibula, lower tibial tuberosity frx…

Posterior Leg splint & stirrup splints

Lacerations: lidocaine allergy… what to use? Lidocaine (amide) vs Esters (cocaine, procaine, benzocaine, tetracaine, chlorprocaine) …(2 “i”s in amides).

Irrigation pressure matters!

Absorbable v Nonabsorbable sutures similar efficacy

Dental Blocks, benzocaine topical followed by inferior alveolar, mental nerve, infraorbital(maxillary)

Peritonsillar Abscesses DO NOT NEED ENT!  It’s an abscess, needs I&D, maybe Abx…

Lateral Canthotomy, know how to do it!

Wrist blocks! ~ Ulnar nerve (lateral to flexor carpi ulnaris, not in artery).  Median Nerve between flexor radialis & flexor longus… Radial nerve (snuffbox under pollicis longus)

 

130p ~ Calcium (Kloss)

Parathyroid gland parafollicular Ccells make calcitonin which “tones” the Calcium “in”to the bones, & lowers serum Ca…  PTH does the opposite, dissolves bone to increase serum Ca!

Dietary calcium increases Ca which increases calcitonin to keep serum level down…

*HYPERCALCEMIA can be primary hyperparathyroidism (high PTH) or paraneoplastic syndrome (high PTHlh), HypervitaminosisD (absorbs more Ca), granulomatous disease…

HYPERCa ~ “Moans, Groans, Stones, Psych Overtones”… short QT.

Hyperparathyroid gets Surgery! (elevated PTH serum, solitary adenoma).   Treat c Massive IVF & then Lasix! (consider bisphosphonate, calcitonin, steroid).  ED levels: >10 to 12 HCTZ… 12 to 14 hyperparathyroid, >14 likely malignancy… consider HemeOnc & ADM.  Bisphosphonates inhibit osteoclast bone dissolution activity.

*HYPOCALCEMIA <9 Chvostek Sign, Trousseau Sign (Carpopedal spasm)… Pseudohypocalcemia can occur in hypoalbuminemia.  HypoMag can also be related to hypoCa… Hyperphosphatemia can lower Ca.   Pancreatitis ~ Saponifacation c Calcium & Lipid…

Rhabdomyolysis releases intracellular phosphate, which binds Ca.  Cows milk has high phos!!! Citrate from blood TFs binds Ca!!  hydroFluoric Acid burns deplete Ca!!  Treat c repletion of CaGluc or CaCl

 

2p ~ Potassium (Kloss)

Normal 3.5 to 5.5, intracellular cation…

*HYPERKALEMIA >6.5, muscle aches, arrhythmias, EKG changes… Hemolysis FalsePOS… get EKG if high.  Pseudohyperkalemia c leukemia & mononucleosis, acidosis, but MOSTLY Renal Failure.  Apoptosis/Rhabdo/Hemolysis causes release of intracellular K!  ACEi & NSAIDs, esp in elderly is bad… Spironolactone/Triamterene K sparing… peaked T, longPR, loss of P, long QRS, Sine wave of death…

Calcium, Glucose, Insulin, IVF, Albuterol, Bicarb, Kayexalate, Dialysis! & EKG…

Intracellular shift by Insulin, Albuterol (glucose transport channel, cAMP~Na/K/ATPase)

Calcium given for EKG changes, especially wide QRS.

Hyperkalemia can cause isolated bradycardia! ~ treat c Calcium.

*HYPOKALEMIA <3.5… weakness, cramps, paralysis… Emesis/Diarrhea, thiazides or loop diuretics, Bartter’s/Gitelman’s syndrome, Albuterol OD, theophylline/caffeine, hyperthyroid, familial hereditary periodic paralysis (intracellular dramatic shift), thyrotoxic periodic paralysis?!

Uwave, flat or inverted T… “Twave is made of potassium”… Low K may also have lowMg!

 

230p ~ Sodium (Joslin)

Dr. Joslin likes Egrets.  Fluid compartments in 70 kg pt… 28L H20 Intracellular, 10.5L Interstitial, 3.5L Intravascular? Regulated by Renin Angiotensin (I &II) Aldosterone Axis, Renal Tubules c Aquaporin channels, ADH/AVP from posterior pituitary…

Angiotensin II is vasoconstrictive, incl afferent renal vasculature & decreases H20 loss…

*HYPONATREMIA <135 low home, <130 low ADM?, <125 very low ADM/MICU, <120 very very low MICU!!!  hypovolemia dt diuretics or GI losses… esp Thiazides! (HCTZ)… beware K loss as well.  SIADH dt CNS Dsx, malignancy, drugs, recent SG… dilutional vs “salt~wasting” disorder…

Treat SIADH c fluid restriction & possible hypertonic saline.  SSRIs can cause SIADH… Cortisol usually suppresses ADH, so Addison’s can result in SIADH.  Pregnancy also dilutes & resets “osmostat”.  Exercise Associated Hyponatremia (half to full marathons, 4 to 6hrs)… No evidence yet of protection c salt pills… Quick Low can be quickly corrected, can give 100cc 3% saline for AMS… up to 800cc bolus has been given with benefit.  Bicarb can be given as 8% substitute.

MDMA can cause significant hyponatremia (~14% of users, independent of ED visit status).  Hyponatremia in Hyperglycemia approximate correction ~ 1.6 mEqNa correction per 100mg/dL elevation >100 of glucose!!!  Although correction factor actually higher c glucose >400!

Rapid Correction ~ beware Central Pontine Myelinolysis!!! ~ Sx in 2 to 6 days! Correction no more than 9 mEq in 24 hr recommended.  100cc of 3% will raise ~1 to 2 mEq.

*HYPERNATREMIA correct c D5W… “Don’t just do something, stand there” ~ mostly nonactionable.

 

3p ~ Pituitary Disease (Farber)

Physiology Anterior & Posterior… Treatment & Imaging…

Anterior: ACTH, GH, TSH, Gonadotropins

Posterior: Prolactin, Oxytocin, ADH, Gonadotropins

Mostly Hypopituitarism… Tumor cause bilateral hemianopsia dt sella turcica impingement…

Pituitary Apoplexy ~ bleeding of adenoma… can become adrenal insufficient & hypothyroid…

*Case: recurrent Sz… Hx Sheehan’s postpartum hemorrhage, lack of breastfeeding… Empty Sella Sign on MRI, may not show on CT?!?! Refractory hypotension c adrenal insufficiency!

Russel’s Viper Venom ~ PanHypoPit?!

Don’t forget steroids in Adrenal Insufficiency!