Podcast # 460: Hunting for PE in Syncope

Author:  Michael Hunt, MD

Educational Pearls:

 

  • Most causes of syncope are benign
  • Pulmonary embolism can result in syncope and is life threatening
  • A recent study of Canadian and US ED patients with syncope showed that 0.4% of patients had a PE at 30 day follow-up
  • PE should always be considered in cases of syncope but overall is a rare cause

 

Editor’s note: this study puts to rest a previous study from 2016 that reported a rate of PE in syncope as high as 1 in 6 in patients admitted to syncope – which was met with much skepticism based on clinical practice.

References

Roncon L, Zuin M, Casazza F, Becattini C, Bilato C, Zonzin P. Impact of syncope and pre-syncope on short-term mortality in patients with acute pulmonary embolism. Eur J Intern Med. 2018 Aug;54:27-33. doi: 10.1016/j.ejim.2018.04.004. Epub 2018 Apr 11. PubMed PMID: 29655808.

Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

Podcast # 459 Clonidine Ingestion

Author:  Julian Orenstein, MD

Educational Pearls:

 

  • Severe clonidine ingestion can present as a fluctuating mental status between typically accompanied by changes in vital signs (hypotension/bradycardia)
  • Respiratory depression requiring intubation is not uncommon

 

References

Isbister GK, Heppell SP, Page CB, Ryan NM. Adult clonidine overdose: prolonged bradycardia and central nervous system depression, but not severe toxicity. Clin Toxicol (Phila). 2017 Mar;55(3):187-192. doi: 10.1080/15563650.2016.1277234. Epub 2017 Jan 20. PubMed PMID: 28107093.

Spiller HA, Klein-Schwartz W, Colvin JM, Villalobos D, Johnson PB, Anderson DL. Toxic clonidine ingestion in children. J Pediatr. 2005 Feb;146(2):263-6. PubMed PMID: 15689921.

Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

Podcast # 458: A Tylenol a Day Keeps the Delirium Away?

Author: Nick Hatch, MD

Educational Pearls:

 

  • A recent study investigated the effect of scheduled IV acetaminophen on the incidence of delirium in post-CABG patients in the ICU
  • The use of scheduled IV acetaminophen reduced the rate of delirium in these patients compared to placebo
  • This may be due to the analgesic effect of acetaminophen and/or less requirement on other deliriogenic medications (opiates)

 

References

Subramaniam B, Shankar P, Shaefi S, Mueller A, O’Gara B, Banner-Goodspeed V, Gallagher J, Gasangwa D, Patxot M, Packiasabapathy S, Mathur P, Eikermann M, Talmor D, Marcantonio ER. Effect of Intravenous Acetaminophen vs Placebo Combined With Propofol or Dexmedetomidine on Postoperative Delirium Among Older Patients Following Cardiac Surgery: The DEXACET Randomized Clinical Trial. JAMA. 2019 Feb 19;321(7):686-696. doi: 10.1001/jama.2019.0234. PubMed PMID: 30778597.

Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

Podcast # 457: Stroke Scores

Author: Jared Scott, MD

Educational Pearls:

 

  • Modified Rankin Score:  measure of disability often used to qualify outcomes following stroke  = no disability, 6=dead, 0-1 indicate good outcome)
    • 0-6 Scale
    • 0-1 indicative of good outcome
  • ASPECT score: uses CT to quantify the extent of changes in the brain due to ischemia
    • 0-10 Scale
    • 10 areas are assessed on non-contrast CT to assess for early stroke changes
    • -1 for each area with these findings
    • 8-10 is indicative of better outcomes

 

References

Aviv RI, Mandelcorn J, Chakraborty S, Gladstone D, Malham S, Tomlinson G, Fox AJ, Symons S. Alberta Stroke Program Early CT Scoring of CT perfusion in early stroke visualization and assessment. AJNR Am J Neuroradiol. 2007 Nov-Dec;28(10):1975-80. Epub 2007 Oct 5. PubMed PMID: 17921237.

https://manual.jointcommission.org/releases/TJC2018A/DataElem0569.html

Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

Podcast # 456 Hypoglycemia: Not feeling so sweet

Author: Jared Scott, MD

Educational Pearls:

 

  • Beta-blockers can mask the effects of hypoglycemia
  • Prolonged/refractory hypoglycemia should raise a suspicion for sulfonylurea (or other oral hypoglycemic) overdose
  • Interventions to reverse hypoglycemia include feeding the patient, IV dextrose, glucagon
  • Octreotide can be used as an antidote with sulfonylurea ingestion 

Editor’s note: Here is an interesting case report on using steroids for severe hypogylcemia caused by insulin overdose. Perhaps another treatment modality to keep in your back pocket?

References

Alsahli M, Gerich JE. Hypoglycemia. Endocrinol Metab Clin North Am. 2013 Dec;42(4):657-76. doi: 10.1016/j.ecl.2013.07.002. Review. PubMed PMID: 24286945.

Moore C, Woollard M. Dextrose 10% or 50% in the treatment of hypoglycaemia out of hospital? A randomised controlled trial.Emerg Med J. 2005 Jul;22(7):512-5. PubMed PMID: 15983093; PubMed Central PMCID: PMC1726850.

Fasano CJ, O’Malley G, Dominici P, Aguilera E, Latta DR. Comparison of octreotide and standard therapy versus standard therapy alone for the treatment of sulfonylurea-induced hypoglycemia. Ann Emerg Med. 2008 Apr;51(4):400-6. Epub 2007 Aug 30. PubMed PMID: 17764782.

Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

Podcast # 455: Hunting for PeeCP

Author: Michael Hunt, MD

Educational Pearls:

 

  • Like all tests, urine toxicology (utox) screens can have false positives
  • Prescription medications such as demerol, antipsychotics, ketamine, and tramadol can all produce a false positive utox for PCP
  • Over-the-counter medication such as dextromethorphan also mimic PCP on utox

 

References

Doyon S. (January 2014). False Positive Urine Screens for Phencyclidine. ToxTidbits. Retrieved from https://www.mdpoison.com/media/SOP/mdpoisoncom/ToxTidbits/2014/January%202014%20ToxTidbits.pdf

Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

Podcast # 454: Tylenol Overdose

Educational Pearls:

 

  • Acetaminophen overdose can also present in patients taking too much over the course of days to weeks – not just intentional ingestions
  • If acute overdose is suspected, refer to the Rumak-Matthew nomogram to guide treatment based on time of ingestion and the time of level
  • In chronic overdose, Tylenol levels will not guide treatment
  • NAPQI is the toxic metabolite of acetaminophen
  • N-acetylcysteine (NAC) can be effective treatment in both acute and chronic overdoses
  • 7.5 g is the daily toxic dose of Tylenol in adults, 150mg/kg in children

 

 

References:

Smilkstein MJ. Acetaminophen. In: Goldfrank’s Toxicologic Emergencies, Goldfrank LR, Flomenbaum NE, Lewin NA, et al (Eds), Appleton & Lange, Stamford 1998. P.541.

Chiew AL, Gluud C, Brok J, Buckley NA. Interventions for paracetamol (acetaminophen) overdose. Cochrane Database Syst Rev. 2018 Feb 23;2:CD003328. doi: 10.1002/14651858.CD003328.pub3. Review. PubMed PMID: 29473717.

Lancaster EM, Hiatt JR, Zarrinpar A. Acetaminophen hepatotoxicity: an updated review. Arch Toxicol. 2015 Feb;89(2):193-9. doi: 10.1007/s00204-014-1432-2. Epub 2014 Dec 24. Review. PubMed PMID: 25537186.

Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

Podcast # 453:  Headache Triggers

Author: Sam Killian, MD

Educational Pearls:

 

  • Headache is a common complaint in the ED. It’s plausible that headaches could be correlated with environmental factors
  • A 2015 study ED visits for headache found that temperature was associated with an increase visits, while higher humidity led to fewer
  • A retrospective study looking over a 10-year period for headache found that there was an increase headache presentations during days with high air pollution

 

References:

Yilmaz M, Gurger M, Atescelik M, Yildiz M, Gurbuz S. Meteorologic parameters and migraine headache: ED study. Am J Emerg Med. 2015 Mar;33(3):409-13. doi: 10.1016/j.ajem.2014.12.056. Epub 2014 Dec 31. PubMed PMID: 25601162.

Szyszkowicz M, Stieb DM, Rowe BH. Air pollution and daily ED visits for migraine and headache in Edmonton, Canada. Am J Emerg Med. 2009 May;27(4):391-6. doi: 10.1016/j.ajem.2008.03.013. PubMed PMID: 19555607.

Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

Podcast # 452: CADASIL

Author: Sam Killian, MD

Educational Pearls:

  • Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy (CADASIL) occurs in 1:100000 individuals
  • The disease is caused by a defect in the NOTCH3 gene on chromosome 19
  • It is an important cause of stroke in young patients
  • Features include ischemia, cognitive deficits, migraines, psychiatric disease, coma, and seizure, all of which is worse with pregnancy
  • Migraine with aura is often the first presenting symptom with onset by age 30
  • Strokes typically can occur by age 50
  • Diagnosis is with MRI for characteristic lesions
  • Unfortunately there is no cure, and treatment is focused on stroke prevention with aspirin and statins

References:

Chabriat H, Joutel A, Dichgans M, Tournier-Lasserve E, Bousser MG. Cadasil. Lancet Neurol. 2009 Jul;8(7):643-53. doi: 10.1016/S1474-4422(09)70127-9. Review. PubMed PMID: 19539236.

Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD

Podcast # 451: NSAIDs

Author: Don Stader, MD

Educational Pearls:

  • Non-steroidal anti-inflammatory drugs (NSAIDs) are effective pain relievers but come with important side effects
  • NSAIDs inhibit COX-1 and/or COX-2, which decreases the production of prostaglandins, which reduce pain and inflammation
  • Side effects of NSAIDS include increased rates myocardial infarction, stroke, and gastrointestinal bleeding, CVA
  • Effective pain reliever doses of many NSAIDs are lower than typically prescribed (i.e. ibuprofen 400 mg is as effective as 800 mg but with less risk of side effects)
  • Topical NSAIDs can be an alternative to reduce systemic effects
  • Selective Cox-2 inhibitors have less GI side effects

Editor note: What is ALTO? It’s alternative to opioids and consists of multi-modal pain control to reduce exposure to opioids. Check out more here and here.

 

References:

Derry S, Wiffen PJ, Kalso EA, Bell RF, Aldington D, Phillips T, Gaskell H, Moore RA. Topical analgesics for acute and chronic pain in adults – an overview of Cochrane Reviews. Cochrane Database Syst Rev. 2017 May 12;5:CD008609. doi: 10.1002/14651858.CD008609.pub2. Review. PubMed PMID: 28497473.

Coxib and traditional NSAID Trialists’ (CNT) Collaboration., Bhala N, Emberson J, Merhi A, Abramson S, Arber N, Baron JA, Bombardier C, Cannon C, Farkouh ME, FitzGerald GA, Goss P, Halls H, Hawk E, Hawkey C, Hennekens C, Hochberg M, Holland LE, Kearney PM, Laine L, Lanas A, Lance P, Laupacis A, Oates J, Patrono C, Schnitzer TJ, Solomon S, Tugwell P, Wilson K, Wittes J, Baigent C. Vascular and upper gastrointestinal effects of non-steroidal anti-inflammatory drugs: meta-analyses of individual participant data from randomised trials. Lancet. 2013 Aug 31;382(9894):769-79. doi: 10.1016/S0140-6736(13)60900-9. Epub 2013 May 30. PubMed PMID: 23726390; PubMed Central PMCID: PMC3778977.

Kaufman DW, Kelly JP, Battista DR, Malone MK, Weinstein RB, Shiffman S. Exceeding the daily dosing limit of nonsteroidal anti-inflammatory drugs among ibuprofen users. Pharmacoepidemiol Drug Saf. 2018 Mar;27(3):322-331. doi: 10.1002/pds.4391. Epub 2018 Jan 26. PubMed PMID: 29372579.

Summarized by Will Dewispelaere, MS3 | Edited by Erik Verzemnieks, MD