Podcast # 469: Go PO

Author: Dave Rosenberg, MD

Educational Pearls:

  • Nothing by mouth (NPO) status routinely used before surgery to reduce the theoretical risk of aspiration
  • However, surgery poses a large physiological stress. Calories and fluid are needed to overcome stresses like these
  • Patients who drank 1/2 strength Gatorade up to 2 hours before surgery did better than those who did not

References

Alyssa Cheng-Cheng Zhu, Aalok Agarwala, Xiaodong Bao. Perioperative Fluid Management in the Enhanced Recovery after Surgery (ERAS) Pathway. Clinics in Colon and Rectal Surgery 2019; 32(02): 114-120. DOI: 10.1055/s-0038-1676476

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

Podcast # 468: Typhlitis

Educational Pearls:

  • Typhlitis refers to the presence of enterocolitis in the setting of neutropenia – also known as neutropenic enterocolitis
  • Commonly a result of chemotherapy for hematologic malignancies.
  • The infection is usually polymicrobial/fungal and can lead to septic shock
  • Usually presents with fever, abdominal pain, with associated GI complaints
  • Workup includes CBC for the ANC (usually <500), and a CT abdomen (look for bowel thickening)
  • Treatment typically with broad-spectrum antibiotics with or without anti-fungal agents
  • Mortality can be as high as 50%

References

Cloutier RL. Neutropenic enterocolitis. Emerg Med Clin North Am. 2009 Aug;27(3):415-22. doi: 10.1016/j.emc.2009.04.002. PubMed PMID: 19646645.

Rodrigues FG, Dasilva G, Wexner SD. Neutropenic enterocolitis. World J Gastroenterol.2017 Jan 7;23(1):42-47. doi: 10.3748/wjg.v23.i1.42. Review. PubMed PMID: 28104979; PubMed Central PMCID: PMC5221285.

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

Podcast # 467: Cauda Equina Syndrome

Author: Erik Verzemnieks, MD

Educational Pearls:

  • Cauda equina syndrome is caused by the compression of the nerve roots that extend beyond the termination of the spinal cord
  • Trauma, infection, hematoma, disc rupture/herniation can cause this – basically anything that can cause pressure and fill space
  • Symptoms can include saddle anesthesia, lower extremity pain, numbness, incontinence, and constipation
  • Post-void residual that is abnormally high may be an indicator
  • MRI is diagnostic modality of choice
  • Emergent surgical decompression is treatment

References

Jalloh I, Minhas P. Delays in the treatment of cauda equina syndrome due to its variable clinical features in patients presenting to the emergency department. Emerg Med J. 2007 Jan;24(1):33-4. doi: 10.1136/emj.2006.038182. PubMed PMID: 17183040; PubMed Central PMCID: PMC2658150.

Podcast # 466: Subacute Sclerosing Panencephalitis

Author: Nicholas Hatch, MD

Educational Pearls:

  • Measles has a period of infectivity starts before the appearance of the characteristic rash, up to 4-5 days
  • A devastating consequence of measles is Subacute Sclerosing Panencephalitis (SSPE), which manifests 7-10 years after the initial measles infection
  • SSPE is a central nervous system disease that has no cure and is nearly universally fatal
  • Educating patients on the importance of vaccination should include discussion of these long term consequences

References

Pallivathucal LB, Noymer A. Subacute sclerosing panencephalitis mortality, United States, 1979-2016: Vaccine-induced declines in SSPE deaths. Vaccine. 2018 Aug 23;36(35):5222-5225. doi: 10.1016/j.vaccine.2018.07.030. Epub 2018 Jul 26. PubMed PMID: 30057285.

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

Podcast # 465: As easy and 1, 2, 10 – Capillary Refill and Sepsis

Author: Ryan Circh, MD

Educational Pearls:

  • The 2019 ANDROMEDA-SHOCK trial compared using serum lactates to capillary refill assessment in septic shock patients to guide resuscitation
  • Capillary refill time was standardized (this is not straightforward):
    • A glass microscope slide was pressed on the ventral side of the right index finger
    • Pressure was increased until the skin was blanched
    • This pressure was sustained for another 10 seconds
    • After pressure was removed, the time to return to normal skin color was timed
    • Greater than three seconds was considered abnormal.
  • No difference between the two groups for mortality at 28-days

Editor’s note: lactates have become so ingrained in our practice it will be tough to change habits but this is an excellent quiver for those of us that hate the over reliance on this lab value alone, despite some of the limitations of the study.

References

Hernández G, Ospina-Tascón GA, Damiani LP, et al. Effect of a Resuscitation Strategy Targeting Peripheral Perfusion Status vs Serum Lactate Levels on 28-Day Mortality Among Patients With Septic Shock: The ANDROMEDA-SHOCK Randomized Clinical Trial. JAMA. 2019;321(7):654–664. doi:10.1001/jama.2019.0071

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

Podcast # 464: Narcan’t?

Author: Aaron Lessen, MD

Educational Pearls:

  • A problem of take-home-naloxone is the administration of it by an able-bodied bystander
  • Australian study looked at consecutive opioid overdose deaths in a single year to identify characteristics of overdose and potential for bystander administered naloxone
  • Of the 235 fatal heroin overdoses reviewed, 83% were alone with only 17% (38 cases) having another person present
  • Half of those in the presence of others had a bystander that was not impaired
  • Take-home-naloxone needs a competent person to administer it. Make sure to review this along with other harm reduction strategies when prescribing/dispensing it to patients

References

Stam NC, Gerostamoulos D, Smith K, Pilgrim JL, Drummer OH. Challenges with take-home naloxone in reducing heroin mortality: a review of fatal heroin overdose cases in Victoria, Australia. Clin Toxicol (Phila). 2019 May;57(5):325-330. doi: 10.1080/15563650.2018.1529319. Epub 2018 Nov 17. PubMed PMID: 30451007.

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

Podcast # 463: Buproprion Overdose

Author: Erik Verzemnieks, MD

Educational Pearls:

  • Buproprion is used as an antidepressant and for smoking cessation
  • Severe buproprion overdoses can cause seizures and lead to cardiac dysrhythmias
  • Benzodiazepines are treatment of choice for seizures
  • Bicarbonate and Interlipid are also possible treatment options with less evidence

References

Stall N, Godwin J, Juurlink D. Bupropion abuse and overdose. CMAJ. 2014 Sep 16;186(13):1015. doi: 10.1503/cmaj.131534. Epub 2014 Apr 28. PubMed PMID: 24778361; PubMed Central PMCID: PMC4162783.

Balit CR, Lynch CN, Isbister GK. Bupropion poisoning: a case series. Med J Aust. 2003 Jan 20;178(2):61-3. PubMed PMID: 12526723.

Bruccoleri RE, Burns MM. A Literature Review of the Use of Sodium Bicarbonate for the Treatment of QRS Widening. J Med Toxicol. 2016 Mar;12(1):121-9. doi: 10.1007/s13181-015-0483-y. Review. PubMed PMID: 26159649; PubMed Central PMCID: PMC4781799.

Podcast # 462: Death after OD

Author: Don Stader, MD

Educational Pearls:

  • 10% of patients seen in the emergency department for opioid overdose patients will die within a year
  • Half of these overdoses will occur in the next month
  • This mortality rate is higher than patients with STEMI, of which 7% will die within one year
  • Take-home naloxone, as well as medication assisted treatment like buprenorphine can save lives

References

Olfson M, Crystal S, Wall M, Wang S, Liu SM, Blanco C. Causes of Death After Nonfatal Opioid Overdose. JAMA Psychiatry. 2018 Aug 1;75(8):820-827. doi: 10.1001/jamapsychiatry.2018.1471. PubMed PMID: 29926090; PubMed Central PMCID: PMC6143082.

Olfson M, Wall M, Wang S, Crystal S, Blanco C. Risks of fatal opioid overdose during the first year following nonfatal overdose.Drug Alcohol Depend. 2018 Sep 1;190:112-119. doi: 10.1016/j.drugalcdep.2018.06.004. Epub 2018 Jul 4. PubMed PMID: 30005310.

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

Podcast # 461: Breath Stacking

Author: Gretchen Hinson, MD

Educational Pearls:

  • Breath stacking occurs when a patient is unable to expire fully before another inspiration
  • In intubated/ventilated patients, this is because adequate time has not passed before exhalation
  • Asthmatics are susceptible due to the prolonged expiratory phase
  • Complications can include reduction in cardiac preload and cardiovascular collapse
  • Pursed-lip breathing can help in the spontaneously breathing patient
  • Intubation may be required when patients present with status asthmaticus and breath stacking

References

Phipps P, Garrard CS. The pulmonary physician in critical care . 12: Acute severe asthma in the intensive care unit. Thorax. 2003 Jan;58(1):81-8. Review. PubMed PMID: 12511728; PubMed Central PMCID: PMC1746457.

Pohlman MC, McCallister KE, Schweickert WD, Pohlman AS, Nigos CP, Krishnan JA, Charbeneau JT, Gehlbach BK, Kress JP, Hall JB. Excessive tidal volume from breath stacking during lung-protective ventilation for acute lung injury. Crit Care Med. 2008 Nov;36(11):3019-23. doi: 10.1097/CCM.0b013e31818b308b. PubMed PMID: 18824913.

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

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