Medical Minute

Podcast # 490: Canadian Syncope Rule

Contributor: Don Stader, MD

Educational Pearls:

  • Syncope is usually benign but can be caused by serious etiologies which include: PE, certain cardiac arrhythmias, AAA, intracranial bleed/stroke
  • The Canadian Syncope Rule appears to identify those patients with syncope and low risk of serious outcomes
  • The score is based on vital signs, EKG and history
  • Negative scores preclude a very low risk of adverse events
  • A calculated score greater than 1 are considered medium risk
  • Scores greater than 4 are high risk
  • Anyone with a medium risk or higher should have their cause thoroughly investigated – which may involve admission or a shared decision making utilizing this rule if discharged

Editor’s note: just remember this rule has not been externally validated… yet

References

https://www.mdcalc.com/canadian-syncope-risk-score

Thiruganasambandamoorthy V, Kwong K, Wells GA, et al. Development of the Canadian Syncope Risk Score to predict serious adverse events after emergency department assessment of syncope. CMAJ. 2016;188(12):E289–E298. doi:10.1503/cmaj.151469

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

Podcast # 489: Bats & Rabies

Contributor: Jared Scott, MD

Educational Pearls:

  • The CDC recommends rabies prophylaxis if there was a direct encounter with a possibly rabid animal except…
  • Bats are treated differently since their bites may be very superficial and not seen/felt. All people with possible close encounters with a bat should receive rabies prophylaxis 
  • From 1990-2007 there were 34 rabies cases associated with bats:
    •  6 of these had a reported bat bite
    • 15 there was a reported exposure but no reported bite
    • 11 had no reported bat exposure but DNA testing revealed that the rabies came from a bat 

References

Pieracci EG, Pearson CM, Wallace RM, Blanton JD, Whitehouse ER, Ma X, Stauffer K, Chipman RB, Olson V. Vital Signs: Trends in Human Rabies Deaths and Exposures – United States, 1938-2018. MMWR Morb Mortal Wkly Rep. 2019 Jun 14;68(23):524-528. doi: 10.15585/mmwr.mm6823e1. PubMed PMID: 31194721; PubMed Central PMCID: PMC6613553.

https://www.cdc.gov/rabies/specific_groups/doctors/index.html

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

Podcast # 488: Dalbavancin

Contributor: Nick Hatch, MD

Educational Pearls:

  • Dalbavancin (Dalvance®) is an antibiotic that can be used for skin and soft tissue infections, providing MRSA coverage
  • It cannot be used in other infections or sepsis
  • Dalbavancin may be appealing as a single dose lasts about 2 weeks
  • Expense is currently a large barrier to use
  • Patients with a vancomycin allergy will likely be allergic to Dalbavancin as the two are related

References

Patel M, Smalley S, Dubrovskaya Y, Siegfried J, Caspers C, Pham V, Press RA, Papadopoulos J. Dalbavancin Use in the Emergency Department Setting. Ann Pharmacother. 2019 Jun 3;:1060028019855159. doi: 10.1177/1060028019855159. [Epub ahead of print] PubMed PMID: 31155916.

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

Podcast # 487: Hunting for Epiglottitis

Contributor: Michael Hunt, MD

Educational Pearls:

  • Due to the efficacy of vaccination, epiglottitis is now more common in adults than children
  • Risk factors include smoking and other immunocompromising co-morbidities, such as diabetes
  • Epiglottitis can present with sore throat and fever, with potential rapid progression to respiratory distress and stridor
  • Diagnosis can include x-ray to look for the “thumbprint sign,” nasofiberoptics, and/or CT
  • Antibiotics are mainstay of treatment but severe cases may need establishment of a definitive airway, typically done with fiberoptics in the operating room due to the potential to irritate the epiglottitis with traditional laryngoscopy

References

Li RM, Kiemeney M. Infections of the Neck. Emerg Med Clin North Am. 2019 Feb;37(1):95-107. doi: 10.1016/j.emc.2018.09.003. Review. PubMed PMID: 30454783.

Tsai YT, Huang EI, Chang GH, Tsai MS, Hsu CM, Yang YH, Lin MH, Liu CY, Li HY. Risk of acute epiglottitis in patients with preexisting diabetes mellitus: A population-based case-control study. PLoS One. 2018;13(6):e0199036. doi: 10.1371/journal.pone.0199036. eCollection 2018. PubMed PMID: 29889887; PubMed Central PMCID: PMC5995441.

Guerra AM, Waseem M. Epiglottitis. [Updated 2018 Nov 15]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430960/

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

Podcast # 486: Morel Mushrooms

Contributor: Nick Hatch, MD

Educational Pearls:

  • True morel mushrooms are commonly foraged
  • The false morel mushroom (Gyromitra esculenta) looks similar to the true morel, but is toxic
  • False morel mushroom toxicity can cause gastrointestinal symptoms as well as liver failure, rhabdomyolysis, and seizures
  • Seizures can be refractory to benzodiazepine therapy and may require use of vitamin B6 and propofol

References

Horowitz KM, Horowitz BZ. Gyromitra Mushroom Toxicity. [Updated 2019 May 12]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2019 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470580/

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

Podcast # 485: Cerebellar Stroke

Contributor: Jared Scott, MD

Educational Pearls:

  • Cerebellar strokes make up a disproportionate number of missed or delayed diagnosis for stroke likely due to the subtle nature of the presentation
  • Cerebellar strokes can present with vomiting, dizziness, and ataxia. 
  • Unlike anterior circulation stroke, exam findings in a cerebellar stroke are ipsilateral to the lesion 
  • On neuro exam, findings may include:
    • Dysmetria: lack of coordination with overshooting/undershooting intended position of limb
    • Dysdiadochokinesia: difficulty with rapid alternating movements
    • Ataxia
    • Nystagmus
  • Consider a cerebellar stroke in patients presenting with vomiting and dizziness without an alternative diagnosis

References

Edlow JA, Newman-Toker DE, Savitz SI. Diagnosis and initial management of cerebellar infarction. Lancet Neurol. 2008 Oct;7(10):951-64. doi: 10.1016/S1474-4422(08)70216-3. Review. PubMed PMID: 18848314.

Datar S, Rabinstein AA. Cerebellar infarction. Neurol Clin. 2014 Nov;32(4):979-91. doi: 10.1016/j.ncl.2014.07.007. Epub 2014 Sep 13. Review. PubMed PMID: 25439292.

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

Podcast # 484: Elevated ICP

Contributor: Charleen Gnisci, PharmD

Educational Pearls:

  • Causes of increased intracranial pressure may include intracranial hemorrhage, malignancy, and trauma. 
  • While definite treatment is to remove the offending cause, there are emergency medicine  
  • Non-pharmacologic methods include elevating head of bed and removing noxious stimuli
  • Pharmacologic options include mannitol and hypertonic saline
  • Hypertonic saline is best delivered through a central line but not required
  • Both these agents benefit from adequate renal function
  • Before using mannitol, be sure to inspect the bag to ensure that it has not precipitated. If it has, try warming the bag before administration. 

References

https://pulmccm.org/critical-care-review/hyperosmolar-therapy-for-increased-intracranial-pressure-review-nejm/

Burgess S, Abu-Laban RB, Slavik RS, Vu EN, Zed PJ. A Systematic Review of Randomized Controlled Trials Comparing Hypertonic Sodium Solutions and Mannitol for Traumatic Brain Injury: Implications for Emergency Department Management. Ann Pharmacother. 2016 Apr;50(4):291-300. doi: 10.1177/1060028016628893. Epub 2016 Jan 29. Review. PubMed PMID: 26825644.

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

Podcast # 483: Dual Antiplatelet Therapy in TIA

Contributor: Don Stader, MD

Educational Pearls:

  • Antiplatelets include Aspirin and Clopidogrel, and are generally used for arterial clotting (MI, stroke)
  • Anticoagulants such as Coumadin, Xarelto, Eliquis are generally used for venous clotting (DVT/PE)
  • Growing data suggests that dual antiplatelet therapy (Aspirin+Clopidogrel) is superior to aspirin alone in reducing stroke for diagnosed with TIA

References:

Kheiri B, Osman M, Abdalla A, Haykal T, Swaid B, Ahmed S, Chahine A, Hassan M, Bachuwa G, Al Qasmi M, Bhatt DL. Clopidogrel and aspirin after ischemic stroke or transient ischemic attack: an updated systematic review and meta-analysis of randomized clinical trials. J Thromb Thrombolysis. 2019 Feb;47(2):233-247. doi: 10.1007/s11239-018-1786-z. PubMed PMID: 30511260.

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

Podcast # 482: Tetracyclines and Hyperpigmentation 

Contributor: Michael Hunt, MD

Educational Pearls:

  • Tetracycline antibiotics such as minocycline can cause greyish hyperpigmentation
  • This hyperpigmentation can sometimes be reversible but not always
  • Minocycline has been used for its effects in autoimmune and neurological diseases, where it is  often taken chronically, which can lead to increased pigmentation  

References

La Placa M, Infusino SD, Balestri R, Vincenzi C. Minocycline-Induced Blue-Gray Discoloration. Skin Appendage Disord. 2017 Aug;3(3):161-162. doi: 10.1159/000469712. Epub 2017 Apr 22. PubMed PMID: 28879193; PubMed Central PMCID: PMC5582477.

 

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

Podcast # 481: Medical Errors and Cognitive Bias

Contributor: Peter Bakes, MD

Educational Pearls:

  • While there are many different types of medical error, one of the most common errors in emergency medicine is failure to diagnose
  • Systematic error in thinking that negatively affects judgement
  • Medical errors are often driven by cognitive biases, which include anchoring, attribution, and availability  
  • Anchoring bias occurs when early information leads to premature closure on a single diagnosis. There is subsequent failure to consider alternative diagnoses, even in the face of conflicting new data and test results.
  • Attribution bias occurs when assumptions about personal and medical characteristics are made about a specific group of people.
  • Availability bias occurs when recent experiences drive providers to over or under consider diagnoses.

References

Croskerry P. Cognitive forcing strategies in clinical decisionmaking. Ann Emerg Med. 2003 Jan;41(1):110-20. doi: 10.1067/mem.2003.22. PubMed PMID: 12514691.

Redelmeier DA. Improving patient care. The cognitive psychology of missed diagnoses. Ann Intern Med. 2005 Jan 18;142(2):115-20. doi: 10.7326/0003-4819-142-2-200501180-00010. PubMed PMID: 15657159.

https://www.nuemblog.com/blog/cognitive-bias

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

 

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