Podcast # 437 : Myasthenia Gravis

 

Podcast # 437 : Myasthenia Gravis

Author: Gretchen Hinson, MD

Educational Pearls:

  • Myasthenia gravis (MG) is an antibody mediated autoimmune disorder against the acetylcholine receptors at the neuromuscular junctions.
  • Bimodal age distribution (20’s-30’s: women; 60’s-70’s: men)
  • Presents with fluctuating muscle weakness typically worse at the end of the day with upper extremities affected more than lower and typically involving facial muscles.
  • Myasthenia crisis occurs when muscle fatigue begins to cause respiratory depression
  • MG was historically diagnosed with the Tensilon test but now often by EMG
  • Treatment of MG crisis involves plasma exchange and IVIG. Those in crisis often require intubation and ICU admission

References:

Gilhus NE. Myasthenia Gravis. N Engl J Med. 2016 Dec 29;375(26):2570-2581. doi: 10.1056/NEJMra1602678. Review. PubMed PMID: 28029925.

Roper J, Fleming ME, Long B, Koyfman A. Myasthenia Gravis and Crisis: Evaluation and Management in the Emergency Department. J Emerg Med. 2017 Dec;53(6):843-853. doi: 10.1016/j.jemermed.2017.06.009. Epub 2017 Sep 12. PubMed PMID: 28916122.

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

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Podcast # 436 : Epinephrine Autoinjectors

Author: Charleen Gnisci, PharmD

Educational Pearls:

 

  • Between 2011 to 2016, Mylan increased EpiPen prices by 400% ($700 for 2 packs)
  • AUVI-Q was recalled in 2012, which left the market share to the EpiPen until recently
  • Teva announced last year it will be making a generic version of the EpiPen retailing around $300 but expected to decrease

 

References:

Kaplan, S. F.D.A. Approves Generic EpiPen That May Be Cheaper. The New York Times, The New York Times, 2018. Retrived from www.nytimes.com/2018/08/16/health/epipen-generic-drug-prices.html.

Tirrell, M.  FDA approves Teva’s generic EpiPen after yearslong delay. 2018. Retrieved from https://www.cnbc.com/2018/08/16/fda-approves-tevas-generic-epipen-after-years-long-delay.html

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

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Podcast # 435 : UCL Injury

Author: Ryan Circh, MD

Educational Pearls:

  • Ulnar collateral ligament injury is often called gamekeeper’s thumb or skier’s thumb
  • Can results from traumatic deviating the thumb radially (abduction)
  • Poor rabbits
  • Have a low threshold for referral to hand surgery for follow up – treatment for minor injuries can be conservative but more severe require surgery to preserve function
  • This injury should be placed in a thumb spica splint
  • Radiographs are often negative unless an avulsion fracture is present

Editor’s note: to test for UCL injuries, I like this.

References:

Schroeder NS, Goldfarb CA. Thumb ulnar collateral and radial collateral ligament injuries. Clin Sports Med. 2015 Jan;34(1):117-26. doi: 10.1016/j.csm.2014.09.004. Epub 2014 Oct 11. Review. PubMed PMID: 25455399.

Madan SS, Pai DR, Kaur A, Dixit R. Injury to ulnar collateral ligament of thumb. Orthop Surg. 2014 Feb;6(1):1-7. doi: 10.1111/os.12084. Review. PubMed PMID: 24590986.

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

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Podcast # 434 : TIA

Author: Peter Bakes, MD

Educational Pearl:

 

  • Transient ischemic attack (TIA) is defined as neurologic symptoms that resolve in 24 hours with no new changes on head imaging
  • Mimics include complex migraine, carotid dissection, seizure (Todd’s paralysis)
  • Typical presentation is with sudden onset of negative symptoms such as numbness, weakness, etc. 
  • Mimics tend to have positive symptoms such as photophobia, pain, etc.

 

References:

Kernan WN, Ovbiagele B, Black HR, et al. Guidelines for the prevention of stroke in patients with stroke and transient ischemic attack: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2014; 45:2160.

Simmons B, et al. Transient Ischemic Attack: Part I. Diagnosis and Evaluation. American Family Physician 2012; 86(6):521-526.

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

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Podcast # 433: Geriatric Ketamine

Author: Michael Hunt, MD

Educational Pearls:

  • Recent study compared ketamine to morphine in elderly patient
  • Ketamine (IV dose 0.3 mg /kg) provided equivalent pain control to morphine  (IV dose 0.1 mg / kg)
  • However, etamine group had much higher rate of side effects, including psychoperceptual
  • A lower does of 0.1 mg / kg given intravenously over 15 minutes might be a better option to start in the elderly population – you can always add more! 

References

Motov S, Mann S, Drapkin J, Butt M, Likourezos A, Yetter E, Brady J, Rothberger N, Gohel A, Flom P, Mai M, Fromm C, Marshall J. Intravenous subdissociative-dose ketamine versus morphine for acute geriatric pain in the Emergency Department: A randomized controlled trial. Am J Emerg Med. 2019 Feb;37(2):220-227. doi: 10.1016/j.ajem.2018.05.030. Epub 2018 May 16. PubMed PMID: 29807629.

 Summarized and edited by Erik Verzemnieks, MD

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Podcast # 432: Hunting for UTIs

Author: Michael Hunt, MD

Educational Pearls:

  • As many as 20% of women in assisted living have asymptomatic bacteriuria
  • This can present a diagnostic conundrum when seeing these patients in the emergency department, particularly for altered mental status and deciding whether to treat
  • True diagnosis of UTI in the emergency department is difficult as true diagnoses required culture results and repeated positive samples
  • Procalcitonin is an emerging biomarker that may be helpful in determining the presence of infection

References:

Cortes-Penfield NW, Trautner BW, Jump RLP. Urinary Tract Infection and Asymptomatic Bacteriuria in Older Adults. Infect Dis Clin North Am. 2017 Dec;31(4):673-688. doi: 10.1016/j.idc.2017.07.002. Review. PubMed PMID: 29079155; PubMed Central PMCID: PMC5802407.

Huang DT, Angus DC, Chang CH, Doi Y, Fine MJ, Kellum JA, Peck-Palmer OM, Pike F, Weissfeld LA, Yabes J, Yealy DM; ProACT Investigators.. Design and rationale of the Procalcitonin Antibiotic Consensus Trial (ProACT), a multicenter randomized trial of procalcitonin antibiotic guidance in lower respiratory tract infection. BMC Emerg Med. 2017 Aug 29;17(1):25. doi: 10.1186/s12873-017-0138-1. PubMed PMID: 28851296; PubMed Central PMCID: PMC5576372.

Summarized by Erik Verzemnieks, MD

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Podcast # 431: Medication Errors

Author: Rachel Brady, MD

Educational Pearls:

  • Medication errors are estimated to be the 3rd leading cause of death
  • A 2016 study estimated 250,000 errors occur per year, with 7000-9000 leading to death
  • About 50% are in the ordering/prescribing phase; 25-30% during administration phase.
  • Overworked and distracted providers are the most common underlying reasons for medication error
  • A 2017 study found 40% of ED nurses witnessed a medication error in the last year

Editor’s Note:  This is a reasonable counterpoint

References

Farag A, Blegen M, Gedney-Lose A, Lose D, Perkhounkova Y. Voluntary Medication Error Reporting by ED Nurses: Examining the Association With Work Environment and Social Capital. J Emerg Nurs. 2017 May;43(3):246-254. doi: 10.1016/j.jen.2016.10.015. Epub 2017 Mar 28. PubMed PMID: 28359712.

Makary MA, Daniel M. Medical error-the third leading cause of death in the US. BMJ. 2016 May 3;353:i2139. doi: 10.1136/bmj.i2139. PubMed PMID: 27143499.

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

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Podcast # 430: Humeral IO

Author: Aaron Lessen, MD

Educational Pearls:

  • Choose the longest needle for the humeral IO
  • Internally rotate and adduct the patients hand (resting on umbilicus) for best access to the site
  • Aim 1 cm superior to the greater tuberosity of the humerus with the needle angled 45 degrees inferiorly
  • Maintaining the line is critical – keep arm internally rotated with sling, tape or whatever works

References

Kovar J, Gillum L. Alternate route: the humerus bone – a viable option for IO access. JEMS. 2010 Aug;35(8):52-9. doi: 10.1016/S0197-2510(10)70207-2. PubMed PMID: 20708143.

http://epmonthly.com/article/get-humeral-io-access/

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Podcast # 429: Oldschool Syphilis Treatment

Author: Chris Holmes, MD

Educational Pearls:

  • In WWI, the 2nd leading cause of soldier disability were STDs.
  • An early treatment of syphilis included topical and inhaled mercury
  • Bloodletting, vitriol, arsenic, and bismuth were other treatments for syphilis.
  • Infecting patients with Malaria and treating the Malaria was also tried
  • Thankfully penicillin was discovered for our syphilis woes

References

Frith J. . Syphilis – Its early history and Treatment until Penicillin and the Debate on its Origins. Journal of Military and Veterans Health. 2012. 20(4): 49-58 https://jmvh.org/article/syphilis-its-early-history-and-treatment-until-penicillin-and-the-debate-on-its-origins/

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD

Podcast # 428: Severe Hypothyroidism

Author: Gretchen Hinson, MD

Educational Pearls:

  • Clinical manifestations of severe hypothyroidism may include:
    • Pale, cool, diaphoretic skin
    • Myxedema is the non-pitting edema seen in hypothyroidism
    • Hypothermia, heart failure, hypotension and shock
    • Shortness of breath
    • Cholestasis, constipation
    • Encephalopathy and coma

 

Mortality is 30-50%

Specific treatment includes thyroid hormone (T3, T4, or both) and glucocorticoids (for potential adrenal insufficiency)

 

References:

Kwaku MP, Burman KD. Myxedema coma. J Intensive Care Med. 2007 Jul-Aug;22(4):224-31. Review. PubMed PMID: 17712058.

Ono Y, Ono S, Yasunaga H, Matsui H, Fushimi K, Tanaka Y. Clinical characteristics and outcomes of myxedema coma: Analysis of a national inpatient database in Japan. J Epidemiol. 2017 Mar;27(3):117-122. doi: 10.1016/j.je.2016.04.002. Epub 2017 Jan 5. PubMed PMID: 28142035; PubMed Central PMCID: PMC5350620.

Lee CH, Wira CR. Severe angioedema in myxedema coma: a difficult airway in a rare endocrine emergency. Am J Emerg Med. 2009 Oct;27(8):1021.e1-2. doi: 10.1016/j.ajem.2008.12.027. PubMed PMID: 19857436.

Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD