Podcast # 366: Ehlers Danlos
Author: Gretchen Hinson, MD.
- Heritable mutation in collagen synthesis and expression commonly resulting in joint hyperextension and skin elasticity.
- Vascular type can result in aneurysm formation and rupture in young patients.
- Patients are also at risk for spontaneous bowel rupture.
- Pregnant women can present with uterine rupture.
Byers PH, Murray ML (2012). “Heritable collagen disorders: the paradigm of Ehlers?Danlos syndrome”. Journal of Investigative Dermatology. 132 (E1): E6?11.
Pepin MG, Byers PH. Ehlers-Danlos Syndrome Type IV. In: Pagon RA, Bird TD, Dolan CR, et al., eds. GeneReviews [Internet]. Seattle (WA): University of Washington, Seattle; 1993-.
Yoneda, A., Okada, K., Okubo, H., Matsuo, M., Kishikawa, H., Naing, B. T., ? Shimada, T. (2014). Spontaneous Colon Perforations Associated with a Vascular Type of Ehlers-Danlos Syndrome. Case Reports in Gastroenterology, 8(2), 175?181. http://doi.org/10.1159/000363373
Author: Erik Verzemnieks, MD
- Single study in Japan demonstrated possible effectiveness of renal colic trigger point
- Patients had injection at the area of maximal tenderness on palpation of the flank
- Compared to a muscle relaxer, injection of local anesthetic at the trigger point had faster time to pain relief and fewer rescue therapies
Iguchi, M et al. Randomized trial of trigger point injection for renal colic. International Journal of Urology. 2002. 9(9): 475-479
Author: Peter Bakes, MD
- Pericarditis, LBBB, LVH and left ventricular aneurysms can all present with ST elevation.
- Ventricular aneurysm will present days after a cardiac event with ST elevation and Q waves in the affected leads.
- Ventricular aneurysms may cause papillary muscle dysfunction with a resultant holosystolic murmur and even heart failure.
Victor F. Froelicher; Jonathan Myers (2006). Exercise and the heart. Elsevier Health Sciences. pp. 138?. ISBN 978-1-4160-0311-3.
Nagle RE, Williams DO. (1974) Proceedings: Natural history of ventricular aneurysm without surgical treatment. British Heart Journal, 36:1037.
- Recent study has shown adjunctive ketamine can be useful in setting of alcohol withdrawal.
- Ketamine was associated with a decrease in the amount of benzodiazepines needed, likelihood of intubation, and a decrease in ICU length of stay by 3 days.
- For patients with benzodiazepine resistance, ketamine was shown to have symptom relief in an hour and decreased rate of benzodiazepine infusion.
Pizon A, Lynch M, Benedict N, et al. 2018. Adjunct Ketamine Use in the Management of Severe Ethanol Withdrawal. Critical Care Medicine. 46(8):e768-e771.
Shah, P., McDowell, M., Ebisu, R. et al. J. Med. Toxicol. (2018). https://doi.org/10.1007/s13181-018-0662-8
Author: John Winkler, MD
- Tall flowering plant with phototoxic sap
- Direct skin contact with the sap can cause the skin to become photosensitive
- Severe blisters and even burns can result
Diebel, Matthew (18 June 2018). “Giant Hogweed, a Plant That Can Cause Burns and Blindness, Found in Virginia”. USA Today.
Author: Peter Bakes, MD
- Important to find out if patients mean dysequilibrium, lightheadedness, or vertigo when patients say they are “dizzy.”
- Differentiate central vs. peripheral vertigo
- Central vertigo typically present with bulbar syndromes (difficulty swallowing, facial nerve palsy) and cerebellar symptoms (ataxia).
- Peripheral vertigo typically present with sudden onset vertigo with nausea and vomiting in the absence of bulbar symptoms.
- Episodic? BPPV or Meniere’s Disease. BPPV has not auditory symptoms and is associated with head position; Meniere’s has hearing loss, tinnitus, and ear fullness.
- Constant? Neuronitis has no auditory symptoms, while labyrinthitis has associated hearing loss/tinnitus and is associated with a recent infection (OM).
Baloh RW. Differentiating between peripheral and central causes of vertigo. Otolaryngol Head Neck Surg 1998; 119:55.
Chase M, Goldstein JN, Selim MH, et al. A prospective pilot study of predictors of acute stroke in emergency department patients with dizziness. Mayo Clin Proc 2014; 89:173.
Kerber KA, Brown DL, Lisabeth LD, et al. Stroke among patients with dizziness, vertigo, and imbalance in the emergency department: a population-based study. Stroke 2006; 37:2484.
Author: Dylan Luyten, MD.
- Dangerous causes of back pain: AAA, cauda equina syndrome, epidural abscess.
- Young person with back pain needs to be evaluated for injection drug use (major risk factor).
- Patient with focal neurologic deficits (FND) require an MRI. Patients without FND can be screened with ESR and CRP. An ESR < 20 & CRP < 1 can effectively rule out epidural abscess as it has a 90% sensitivity for epidural abscess.
- Treatment is IV antibiotics and surgical debridement.
Davis DP et al. Prospective evaluation of a clinical decision guideline to diagnose spinal epidural abscess in patients who present to the emergency department with spine pain, Journal of Neurosurgery: Spine. 2011. 14:765-770.
Author: Sam Killian, MD.
- Computer interpretation has a very good negative predictive value of a normal EKG (99%).
- Of 222 interpreted as “normal,” 13 were deemed to have some abnormality by a cardiologist in a recent study.
- Those 13 EKG’s were read by 2 ER docs, and only 1 missed interpretation warranted a move from triage to a bed.
Katie E. Hughes KE., Scott M. Lewis SM., Laurence Katz and Jonathan Jones Safety of Computer Interpretation of Normal Triage Electrocardiograms. 2017. Academic Emergency Medicine 24(1):120-124. http://onlinelibrary.wiley.com/doi/10.1111/acem.13067/full.
- Otic (ear) specific antibiotic drops can be expensive
- Opthalmic (eye) versions are basically identical and can be used as an affordable substitute as many are on the $4 drug lists
- But don’t do the reverse (don’t use ear drops on the eye)
- Use caution when administering aminoglycoside if tympanic membrane rupture is present
Author: Michael Hunt, MD
- Toxicity happens from local anesthetics being given too fast, too much, or in the unintended spot
- Systemic toxicity manifests first with neurologic symptoms like circumoral numbness, tinnitus, blurred vision, nausea, and even seizures. Severe toxicity can then progress to arrhythmias and cardiac arrest.
- Maximum doses of lidocaine: 4 mg/kg; and with epinephrine: 7mg/kg.
- Maximum dose of bupivacaine: 2mg/kg; with epinephrine 3mg/kg
Editor note: treat seizures with benzodiazepines and avoid propofol for sedation; severe toxicity can also be treated with a 20% lipid emulsion, though there is debate on its efficacy
Dickerson DM, Apfelbaum JL. Local anesthetic systemic toxicity. Aesthet Surg J. 2014 Sep;34(7):1111-9. doi: 10.1177/1090820X14543102.
Neal JM, Mulroy MF, Weinberg GL; American Society of Regional Anesthesia and Pain Medicine.. American Society of Regional Anesthesia and Pain Medicine checklist for managing local anesthetic systemic toxicity: 2012 version. Reg Anesth Pain Med. 2012 Jan-Feb;37(1):16-8. doi: 10.1097/AAP.0b013e31822e0d8a.
Vasques F, Behr AU, Weinberg G, Ori C, Di Gregorio G. A Review of Local Anesthetic Systemic Toxicity Cases Since Publication of the American Society of Regional Anesthesia Recommendations: To Whom It May Concern. Reg Anesth Pain Med. 2015 Nov-Dec;40(6):698-705. doi: 10.1097/AAP.0000000000000320.