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 # 414: Acute Limb Ischemia

Author: Dylan Luyten, MD

Educational Pearls:

 

  • Symptoms of acute limb ischemia are the 5 P’s: Pulselessness, pain, pallor, paresthesias, and poikilothermia
  • Sudden onset of non-traumatic extremity pain should raise concern for this diagnosis
  • Obtaining an ankle brachial index (ABI) can help confirm the diagnosis
  • Consultation with vascular surgery should be immediately after the clinical diagnosis and before any further delays to obtain further imaging

 

References:

Santistevan JR. Acute Limb Ischemia: An Emergency Medicine Approach. Emerg Med Clin North Am. 2017 Nov;35(4):889-909. doi: 10.1016/j.emc.2017.07.006. Epub 2017 Aug 23. Review. PubMed PMID: 28987435.

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

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Podcast # 413: Fascia Iliaca Block

Author: Katie Sprinkle, MD

Educational Pearls:

 

  • The fascia iliaca block is useful for hip and proximal femur fractures.
  • Typically involves injecting 40-60 mL of diluted bupivacaine (0.25%) under the fascia iliaca (or other anesthetic)
  • Anesthesia is achieved of the femoral, obturator, and lateral femoral cutaneous nerves.
  • Monitor for signs of bupivacaine toxicity (paresthesias, AMS, seizures, arrhythmias)
  • Intralipid can be an effective treatment for life-threatening toxicity

 

References:

Hoegberg LC, Bania TC, Lavergne V, Bailey B, Turgeon AF, Thomas SH, Morris M, Miller-Nesbitt A, M├ęgarbane B, Magder S, Gosselin S; Lipid Emulsion Workgroup.. Systematic review of the effect of intravenous lipid emulsion therapy for local anesthetic toxicity. Clin Toxicol (Phila). 2016 Mar;54(3):167-93. doi: 10.3109/15563650.2015.1121270. Epub 2016 Feb 6. Review. PubMed PMID: 26853119.

https://www.acepnow.com/article/control-hip-fracture-pain-without-opioids-using-ultrasound-guided-fascia-iliaca-compartment-block/?singlepage=1&theme=print-friendly

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

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Podcast #412: tPa Mission Creep

Author: Aaron Lessen, MD

Educational Pearls:

  • Patients with “minor” strokes with NIHSS 0 to 5  can still end up having poor long-term outcomes
  • Recent study compared use of alteplase vs. aspirin for these patients and saw no difference in regards to favorable neurologic outcome at 90 days
  • Study was ended early due to patient recruitment difficulties

Editor’s note: though ended early, it is debatable whether even if appropriately powered there would have been an identifiable benefit

 

References:

Khatri P, Kleindorfer DO, Devlin T, Sawyer RN Jr, Starr M, Mejilla J, Broderick J, Chatterjee A, Jauch EC, Levine SR, Romano JG, Saver JL, Vagal A, Purdon B, Devenport J, Pavlov A, Yeatts SD; PRISMS Investigators. Effect of Alteplase vs Aspirin on Functional Outcome for Patients With Acute Ischemic Stroke and Minor Nondisabling Neurologic Deficits: The PRISMS Randomized Clinical Trial. JAMA. 2018 Jul 10;320(2):156-166. doi: 10.1001/jama.2018.8496. PubMed PMID: 29998337.

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

 

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