Medical Minute

Podcast #500: 2018-19 Rapid Fire EM Literature Review

Author: Dave Saintsing

Educational Pearls:

  • Poor sleep is an independent risk factor for development of health problems such as type 2 diabetes.  A 2019 study, randomized participants to 3 groups: 9 hours of sleep, 5 hours of sleep with weekend catch-up sleep, and 5 hours of sleep without catch-up sleep.  In the sleep deprived (5 hour) groups, there was significantly more insulin resistance, calorie intake, and weight gain regardless of catch-up sleep.
  • Tramadol is prescribed 25 million times a year in the USA, usually to avoid prescribing traditional opiates such as Percocet or Oxycodone. Tramadol has complex pharmacology in that is is both an SNRI and mu-opiate agonist after metabolism in the liver. The pharmacogenetics of this vary greatly between people. Many people have rapid metabolism that will lead to increased opiate effects. Other medications interfere with metabolism (such as SSRI’s). A recent study demonstrated increased risk of hypoglycemia in diabetics taking Tramadol. Use caution when prescribing this drug.
  • Sepsis resuscitation has traditionally been gauged by following lactate levels on the  presumption that lactate is an adequate marker of organ perfusion. Unfortunately, lactate levels are often elevated by medications and other health conditions such as kidney or liver disease, making lactate an often ineffective biomarker for perfusion. The Andromeda-Shock trial compared using capillary refill to lactate as guides for resuscitation with the primary endpoint of reducing 28-day mortality.  The capillary refill group had a 9% absolute risk reduction in mortality, but this did not reach statistical significance. However, capillary refill can be used as another data point while resuscitating your septic patients.
  • When should you start pressors for patients in septic shock? A 2019 study compared routine resuscitation (30cc/kg fluid bolus) to initiation of norepinephrine with the first 30cc/kg crystalloid. They found that the early pressor group had significantly more “shock control” (MAP>65) at 6 hours, compared to the control group. While there was a trend towards less mortality in the early pressor group, it was not statistically significant. Keep an eye out for more studies in this area!
  • A recent study in JAMA found that 88% of deaths from sepsis were unavoidable, due to severe chronic comorbidities. Remember that patients will still die from septic shock despite your best efforts and knowledge of the newest literature.

References

Depner CM, Melanson EL, Eckel RH, Snell-Bergeon JK, Perreault L, Bergman BC, Higgins JA, Guerin MK, Stothard ER, Morton SJ, Wright KP Jr. Curr Biol. 2019 Feb 11. pii: S0960-9822(19)30098-3. doi: 10.1016/j.cub.2019.01.069. [Epub ahead of print]. PMID:30827911.

Fournier J, Azoulay L, Yin H, Montastruc J, Suissa S. Tramadol Use and the Risk of Hospitalization for Hypoglycemia in Patients With Noncancer Pain. JAMA Intern Med. 2015;175(2):186–193. doi:10.1001/jamainternmed.2014.6512

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. Published online February 17, 2019321(7):654–664. doi:10.1001/jama.2019.0071

Permpikul C, Tongyoo S, Viarasilpa T, Trainarongsakul T, Chakorn T, Udompanturak S. Early Use of Norepinephrine in Septic Shock Resuscitation (CENSER). A Randomized Trial. Am J Respir Crit Care Med. 2019 May 1;199(9):1097-1105. doi: 10.1164/rccm.201806-1034OC.

Rhee C, Jones TM, Hamad Y, et al. Prevalence, Underlying Causes, and Preventability of Sepsis-Associated Mortality in US Acute Care Hospitals. JAMA Netw Open. Published online February 15, 20192(2):e187571. doi:10.1001/jamanetworkopen.2018.7571

Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

From CarePoint PA Academy, 2019

Podcast #499: Posterior Circulation Ischemia

Podcast # 499: Posterior Circulation Strokes

Contributor: Neal O’Connor, MD

Educational Pearls:

  • Dizziness is a very common complaint in the emergency department, but how can we find patients with a dangerous cause of their symptoms, namely a posterior circulation stroke?
  • Consider a posterior circulation stroke in those with an abrupt onset of headache with neck pain, balance problem, blurred vision, or dysphagia
  • Thorough cranial nerve exam can be important to screen for posterior circulation stroke, as much of the brainstem is supplied by the posterior circulation.
  • The most common posterior circulation stroke is a lateral medullary infarct (Wallenberg Syndrome), which produces dysphagia due to cranial nerve IX and XII involvement
  • Other physical exam findings include truncal ataxia, extremity ataxia, visual field cuts, and Horner syndrome (Ptosis, Miosis, Anhidrosis)
  • The HINTS exam (Head Impulse – Nystagmus – Test of Skew)can be used to differentiate between peripheral and central causes of dizziness
  • Concerning exam findings for central cause may include vertical nystagmus, gaze skew, or inability to track with head impulse

References

Áine Merwick, David Werring. Posterior circulation ischaemic stroke. BMJ 2014;348:g3175 doi: 10.1136/bmj.g3175

Kattah JC, Talkad AV, Wang DZ, Hsieh YH, Newman-Toker DE. HINTS to diagnose stroke in the acute vestibular syndrome: three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging. Stroke. 2009;40(11):3504–3510. doi:10.1161/STROKEAHA.109.551234

Nouh A, Remke J, Ruland S. Ischemic posterior circulation stroke: a review of anatomy, clinical presentations, diagnosis, and current management. Front Neurol. 2014;5:30. Published 2014 Apr 7. doi:10.3389/fneur.2014.00030

From CarePoint PA Academy, 2019

Podcast # 498: Ortho Tips

Author: Susan Ryan, DO

Educational Pearls:

  • General orthopedic principles:
    • Examine above and below the injury
    • Document neurovascular status
    • X-ray imaging typically requires three different views
  • Fracture description should include name the bone, location of fracture, degree of displacement, and if it is closed or open
  • Osgood-Schlatter (tibia) and Sever’s (calcaneus) disease are apophyseal injuries caused by ligaments that are “stronger” than the bones they attach to
  • When looking for scaphoid injuries, get extra (turned) views of the wrist. Remember that the scaphoid has a reverse blood flow and is prone to avascular necrosis
  • Acute carpal tunnel syndrome can occur in forearm fractures. Again, don’t forget your neuro exam.
  • Distal radial-ulnar joint (DRUJ) injuries are caused by tears in the ligaments that stabilize the wrist. They cause chronic pain with pronation and supination.
  • Posterior effusions in the elbow in the 90 degree view nearly always indicate a fracture
  • Lisfranc injuries are commonly missed, especially if the mechanism is perceived as low energy. Look for the “fleck sign”, which is an avulsion fracture at the base of 2nd metatarsal
  • Syndesmotic injuries of the ankle (a high ankle sprain) can be identified through the squeeze test
  • Knee dislocations are neurovascular emergencies

Podcast #497: Does my patient with CP have ACS?

Author: Dylan Luyten, MD

Educational Pearls:

  • While certain aspects of the history, exam, and EKG may increase likelihood of ACS, there is no one element that performs well on its own
  • Elements of the history have been found to have different likelihood ratios, which can increase or decrease the probability of a patient having ACS
  • Likelihood ratios greater than one increase the chance of the patient having the disease. Ratios less than one decrease it
  • Bilateral arm radiation is one of very few historical features that increases the likelihood of ACS
  • ST depressions are one of the few EKG findings with a high LR for ACS
  • Scoring systems such as the HEART score can be useful to risk stratify your patients

References

Fanaroff AC, Rymer JA, Goldstein SA, Simel DL, Newby LK. Does This Patient With Chest Pain Have Acute Coronary Syndrome?: The Rational Clinical Examination Systematic Review. JAMA. 2015 Nov 10;314(18):1955-65. doi: 10.1001/jama.2015.12735. Review. PubMed PMID: 26547467.

Backus BE, Six AJ, Kelder JC, Bosschaert MA, Mast EG, Mosterd A, Veldkamp RF, Wardeh AJ, Tio R, Braam R, Monnink SH, van Tooren R, Mast TP, van den Akker F, Cramer MJ, Poldervaart JM, Hoes AW, Doevendans PA. A prospective validation of the HEART score for chest pain patients at the emergency department. Int J Cardiol. 2013 Oct 3;168(3):2153-8. doi: 10.1016/j.ijcard.2013.01.255. Epub 2013 Mar 7. PubMed PMID: 23465250.

From CarePoint PA Academy, 2019

Podcast # 496: Hallucinogens

Author: David Holland, MD

Educational Pearls:

  • Hallucinogenics have been used for a variety of cultural and religious reasons for thousands of years
  • In the 1960’s a Harvard professor began experimenting with psilocybin mushrooms. There was resulting public outcry, eventually leading to all hallucinogens being listed as schedule I drugs
  • Common hallucinogens include: LSD (acid), Mescaline (peyote), DMT (ayahuasca), Psilocybin (mushrooms), MDMA (ecstacy)
  • Effects vary by specific drug but may include auditory/visual hallucinations, increased empathy, loss of fear
  • Physiologic effects often include mydriasis, tachycardia, hyperthermia and hypertension 
  • Recent neuroimaging studies have shown increased neural connectivity in people after administration of hallucinogens
  • Each hallucinogen has a specific dose and duration, some can last half a day or more 

References

Heal DJ, Gosden J, Smith SL. Evaluating the abuse potential of psychedelic drugs as part of the safety pharmacology assessment for medical use in humans.Neuropharmacology. 2018 Nov;142:89-115. doi: 10.1016/j.neuropharm.2018.01.049. Epub 2018 Feb 8. Review. PubMed PMID: 29427652.

Garcia-Romeu A, Kersgaard B, Addy PH. Clinical applications of hallucinogens: A review. Exp Clin Psychopharmacol. 2016 Aug;24(4):229-68. doi: 10.1037/pha0000084. Review. PubMed PMID: 27454674; PubMed Central PMCID: PMC5001686.

Bogenschutz MP, Johnson MW. Classic hallucinogens in the treatment of addictions.Prog Neuropsychopharmacol Biol Psychiatry. 2016 Jan 4;64:250-8. doi: 10.1016/j.pnpbp.2015.03.002. Epub 2015 Mar 14. Review. PubMed PMID: 25784600.

From CarePoint PA Academy

Podcast # 495: Trauma in the Elderly 

Author: Rachel Brady, MD

Educational Pearls:

  • Elderly patients (>65 years old) have a higher trauma mortality compared to younger patients, even though they have lower mechanisms of injury
  • Elder trauma is often under-triaged due to low-energy mechanisms and lack of physiologic response due to age and medications such as beta-blockers. Do not be reassured by normal vital signs.
  • Image elderly patients with head injury aggressively since they are at high risk of intracranial bleeds
  • Be sure to ask about anticoagulation use. Up to 15% of asymptomatic head injury patients  on warfarin will have intracranial bleeds on CT.
  • Be on the lookout for unstable C-spine injuries such as type II odontoid fractures
  • Central cord syndrome is a possibility with any neck extension injury
  • Rib fractures are common, with mortality increasing greatly with more than 2 ribs involved
  • The elderly are more prone to musculoskeletal injuries due to loss of bone density
  • Always discuss goals of care with these patients

References

Rathlev NK, Medzon R, Lowery D, Pollack C, Bracken M, Barest G, Wolfson AB, Hoffman JR, Mower WR. Intracranial pathology in elders with blunt head trauma. Acad Emerg Med. 2006 Mar;13(3):302-7. doi: 10.1197/j.aem.2005.10.015. PubMed PMID: 16514123.

Keller JM, Sciadini MF, Sinclair E, O’Toole RV. Geriatric trauma: demographics, injuries, and mortality. J Orthop Trauma. 2012 Sep;26(9):e161-5. doi: 10.1097/BOT.0b013e3182324460. PubMed PMID: 22377505.

Bulger EM, Arneson MA, Mock CN, Jurkovich GJ. Rib fractures in the elderly. J Trauma.2000 Jun;48(6):1040-6; discussion 1046-7. doi: 10.1097/00005373-200006000-00007. PubMed PMID: 10866248.

Hashmi A, Ibrahim-Zada I, Rhee P, Aziz H, Fain MJ, Friese RS, Joseph B. Predictors of mortality in geriatric trauma patients: a systematic review and meta-analysis. J Trauma Acute Care Surg. 2014 Mar;76(3):894-901. doi: 10.1097/TA.0b013e3182ab0763. Review. PubMed PMID: 24553567.

Brooks SE, Peetz AB. Evidence-Based Care of Geriatric Trauma Patients. Surg Clin North Am. 2017 Oct;97(5):1157-1174. doi: 10.1016/j.suc.2017.06.006. Review. PubMed PMID: 28958363.

Podcast #494: A Standard Toxicology Approach

Contributor: JP Brewer, MD

Educational Pearls:

  • Obtaining collateral is often vital to determine the potential drugs accessible to the patient – this may include medications found in their medicine cabinet prescribed to them or a family member
  • After this, use ancillary sources such as EMS, family/friends, and police to determine the patient’s last normal, PMH and medications
  • To help separate toxidromes, pupillary exam and skin exam are helpful
  • Important physical exam clues in toxicology include the pupils and the skin
  • Adjunct laboratory evaluation may include liver function tests, acetaminophen level, salicylate levels, urine drug screens, particularly in unknown ingestions
  • Your local toxicologist (if you are fortunate to have one) or the Poison Center can always provide assistance in treatment and workup – consider involving them early

References

Erickson TB, Thompson TM, Lu JJ. The approach to the patient with an unknown overdose. Emerg Med Clin North Am 2007; 25:249.

Podcast # 493: One Pill for the Kill

Contributor: JP Brewer, MD

Educational Pearls:

  • Because of their smaller size, there are a variety of adult-dose pills that are potentially toxic to children.
  • The most common categories of medications that may be toxic include cardiac, diabetic, pain, psychiatric, anti-malarial, and herbals/caustics
  • Oral hypoglycemics such as sulfonylureas can be particularly dangerous in children.
  • Opiates and benzodiazepines have the potential for respiratory arrest
  • Anti-malarial medications are arrhythmogenic to children
  • Camphor, batteries, oil of wintergreen (for the salicylate), and household caustic materials are dangerous non-pharmacologic ingestions to think about in children
  • If you encounter any of the above situations, consult your local poison control center 1-800-222-1222 or your toxicologist if you are lucky enough to have one on call

References

https://www.acep.org/how-we-serve/sections/toxicology/news/march-2016/one-pill-or-sip-can-kill/

Schillie SF, Shehab N, Thomas KE, Budnitz DS. Medication overdoses leading to emergency department visits among children. Am J Prev Med 2009;37:181-7.

Oz B, Levichek Z, Koren G. Medications That Can Be Fatal For a Toddler with One Tablet or Teaspoonful A 2004 Update. Pediatric Drugs, 2004; 6(2): 123-126

Podcast # 492: Pain While on Buprenorphine

Contributor: Don Stader, MD

Educational Pearls:

  • Buprenorphine is a partial Mu-agonist and binds with higher affinity than most opioids
  • Pain management with opioids therefore can be difficult in patients taking buprenorphine
  • Ketamine is a good option for pain control in these patients
  • You can also consider using additional buprenorphine
  • Intravenous buprenorphine is dosed differently than oral formulations
  • Consider receptor availability – patients on high doses of buprenorphine (32mg) will have few Mu receptors available, and thus will likely not benefit from opiate pain meds of any kind

References

Alford DP, Compton P, Samet JH. Acute pain management for patients receiving maintenance methadone or buprenorphine therapy. Ann Intern Med. 2006;144(2):127–134.

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

Podcast # 491: Buprenorphine for Withdrawal

Educational Pearls:

  • Buprenorphine is a semi-synthetic derivative of the opium poppy
  • FDA approved for the treatment of opiate use disorder and chronic pain
  • Benefit in emergency department use is the ceiling effect – producing less euphoria as well as respiratory depression with higher doses
  • It has an onset of 30-60 minutes, peak effect at 1-4 hours
  • Duration of action depends is dose dependent, typically 6-12 hours, but can be as long as 24-72 hours in doses over 16 mg
  • Use buprenorphine in those in moderate to severe opiate withdrawal
  • Clinical Opioid Withdrawal Scale (COWS) can be used to assess and score severity of withdrawal
  • A reasonable starting dose is 8mg. A second dose can be given after an hour, ranging from 8-24 mg depending on symptoms still present
  • Buprenorphine can induce withdrawals so someone needs to be in true withdrawals for it to provide benefit

References

https://www.mdcalc.com/cows-score-opiate-withdrawal

https://ed-bridge.org

Herring AA, Perrone J, Nelson LS. Managing Opioid Withdrawal in the Emergency Department With Buprenorphine. Ann Emerg Med. 2019 May;73(5):481-487. doi: 10.1016/j.annemergmed.2018.11.032. Epub 2019 Jan 5. Review. PubMed PMID: 30616926.

Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD

 

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