Toxicology Board Review with Dr. Edward Guo

December 15, 2023December 3, 2023 Edward GuoLeave a comment

A 45 year old male with a history of autism, depression, and epilepsy presents for an overdose. He was found in his bedroom obtunded by family with empty pill bottles. His medication list includes valproic acid and fluoxetine. He was intubated by EMS for airway protection. His vital signs include Temp 98.0F, HR 108, BP 100/60, RR 16, SpO2 99% on 40% FiO2. On exam, he has a GCS of E1 V1T M4 with minimal sedation. Pupils are equal and reactive to light. There is no rigidity or clonus. Labs are notable for elevated LFTs and ammonia. Which of the following medications should be used for the treatment of this patient’s suspected overdose?

A: Cyproheptidine

B: Levo-carnitine

C: Meropenem

D: B & C

Answer: B & C (Levo-carnitine & Meropenem)

This patient’s presentation is consistent with valproic acid overdose. The most common exam finding is CNS depression which can range from drowsiness to coma. Serotonin syndrome classically presents with hyperthermia and clonus. Treatment of serotonin syndrome typically includes supportive care with benzodiazepines and cyproheptadine with consultation of a toxicologist. Treatment of valproic acid toxicity includes GI decontamination and levo-carnitine as it can increase metabolism of valproic acid, hasten resolution of coma, and prevent hepatic dysfunction. Newer studies have shown that concomitant use of carbapenems (specifically meropenem) with valproic acid causes drug-drug interactions that lead to decreased serum valproic acid concentrations. Dialysis can be considered for severe overdoses with hemodynamic instability or acidosis that does not respond to initial therapy.

References:

LoVecchio F. Anticonvulsants. In: Tintinalli JE, Ma O, Yealy DM, Meckler GD, Stapczynski J, Cline DM, Thomas SH. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw Hill; 2020.

Al-Quteimat O, Laila A. Valproate Interaction With Carbapenems: Review and Recommendations. Hosp Pharm. 2020;55(3):181-187. doi:10.1177/0018578719831974Al-Quteimat, O., & Laila, A. (2020). Valproate Interaction With Carbapenems: Review and Recommendations. Hospital pharmacy, 55(3), 181–187. https://doi.org/10.1177/0018578719831974

Special shoutout to our ED pharmacists that educated us on this topic!

Thursday Conference Content & EKG Review

The HEART Score by Dr. Meg Chamberlain

December 14, 2023December 1, 2023 John CafaroLeave a comment

Wednesday Image Review

What’s the Diagnosis? By Dr. Carlos Cevallos

December 13, 2023December 12, 2023 Edward GuoLeave a comment

Case: A 60 year old female with a past medical history of a left hip replacement presents with a chief complaint of left hip pain after a fall. Since the fall she has been unable to move her hip and on exam the left leg is visibly shortened, adducted, and internally rotated, otherwise the patient is neurovascularly intact. X-ray reveals the image below. What’s the diagnosis?

Answer: Posterior Hip Dislocation

Case Continued: Under procedural sedation with keto-fol the hip was reduced successfully using the Captain Morgan technique as demonstrated in post-reduction XRs below. The patient was then placed in a knee immobilizer and discharged with an abduction pillow and orthopedic follow up.

Over 90% of hip dislocations are posterior
Up to 10% of prosthetic hips undergo dislocation with the vast majority being posterior
Native hip dislocations are an orthopedic emergency and should be reduced as soon as possible!
- The risk of avascular necrosis increases from <10% to about 25% when reduction is extended from 10 hours to 15 hours
- Prosthetic hip dislocation is not as time sensitive as there is no blood flow to the joint, thus no risk of avascular necrosis.
- Sciatic nerve injury can occur in both native and prosthetic posterior hip dislocations
There are many different reduction techniques including but not limited to:
- Captain Morgan: https://www.youtube.com/watch?v=lQMWaFX-MeQ
- Whistler technique: https://www.youtube.com/watch?v=Fl71ztyFU7I
- Allis technique: https://www.youtube.com/watch?v=eMVsjwAukU4
- Below is a comprehensive guide to multiple different techniques:
  - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4821229/
A CT should be obtained post-reduction of native hips to rule out fractures/loose debris

Resources:

https://www.merckmanuals.com/professional/injuries-poisoning/dislocations/hip-dislocations#v35074190

Tintinalli’s Emergency Medicine Cases A comprehensive Study Guide 9th Edition, Judith Tintinalli

Tuesday Advanced Cases & Procedure Pearls

Electrical Storm by Dr. Edward Guo

December 12, 2023 Edward GuoLeave a comment

HPI:

A 58 year old male with a past medical history of CAD s/p PCI, cardiomyopathy with EF 30-35% c/b VF arrest s/p ICD presents via EMS as a STEMI alert.
While en route, patient had episode of VT on the cardiac monitor and was defibrillated by the ICD almost immediately, returning to narrow complex rhythm.
He remains neurologically intact and states that 1 hour ago he started having crushing substernal chest pain and feels like he is going to die.

Physical Exam:

Vitals: BP 84/40, HR 39, RR 20, SpO2 94%

GCS 15, moves all extremities equally
Appears pale, diaphoretic, in obvious extremis
Bradycardic with cool extremities
Trace pitting edema in bilateral lower extremities

EKG interpretation: Junctional rhythm with PVCs in pattern of bigeminy. Inferior STEMI with reciprocal ST segment depressions in lateral leads.

Case continued:

Patient was given 324mg aspirin en route by EMS. Additionally given 300 mg amiodarone bolus, 4000 U heparin bolus, and 500 cc LR bolus upon arrival to ED.
During initial resuscitation, cardiac rhythm converts to VT and patient is immediately defibrillated by ICD with ROSC and remains neurologically intact.
Patient persistently hypotensive and norepinephrine infusion is initiated to MAP > 65.
Patient experiences another episode of VT and is again immediately defibrillated by ICD with ROSC and remains neurologically intact.
Decision is made in junction with cardiology and interventional cardiology to transport patient immediately to catheterization lab. During the procedure, the patient continues to have multiple episodes of VT and VFib and undergoes general anesthesia and is intubated. The angiogram demonstrates a 100% occlusion of the proximal RCA. The patient recovers in the CCU and was discharged on hospital day 5.

Pearls:

Electrical storm is defined by 3 or more sustained episodes of VT, VFib, or appropriate shocks from an ICD within 24 hours.
Initial management adheres to ACLS protocol with strict attention to airway, breathing, and circulation.
- Medications include epinephrine, amiodarone, and lidocaine
Consider the following for refractory VT/VF (electrical storm):
- Esmolol or other beta blockade agents
- Dual sequential defibrillation
  - https://www.youtube.com/watch?v=Ov-BBUhKdJU
- Ultrasound guided stellate ganglion block
  - https://www.youtube.com/watch?v=B6ROeVFUJSY
- VA-ECMO

References:

Eifling M, Razavi M, Massumi A. The evaluation and management of electrical storm. Tex Heart Inst J. 2011;38(2):111-121.

Driver BE, Debaty G, Plummer DW, Smith SW. Use of esmolol after failure of standard cardiopulmonary resuscitation to treat patients with refractory ventricular fibrillation. Resuscitation. 2014;85(10):1337-1341. doi:10.1016/j.resuscitation.2014.06.032

Monday Back to Basics & Pharmacology

From the Archives: Baby, It’s Cold Outside: Death by Hypothermia with Dr. Kate Ginty

December 11, 2023December 7, 2023 Erica WestlakeLeave a comment

The Basics

On average, approximately 1300 Americans die of hypothermia each year
These don’t all occur in cold mountain regions. Homelessness, mental illness and substance abuse are important risk factors, particularly in urban areas.
Not all hypothermia cases are related to exposure! Other causes include hypoglycemia, hypothyroidism, hypoadrenalism, hypopituitarism, CNS dysfunction, drug intoxication, sepsis and dermal disease
Hypothermia = core body temperature < 35 degrees C (95 degrees F)
Mild hypothermia (32-35 degrees C): present with shivering, tachycardia, tachypnea and hypertension
< 32 degrees C: shivering stops and HR and BP decrease; patients become confused, lethargic and then comatose; Reflexes are lost, RR increases; bronchorrea occurs; aspiration is common; cold diuresis and hemoconcentration occur
As temp lowers, sinus bradycardia develops into atrial fibrillation with slow ventricular response to ventricular fibrillation to asystole. At temps < 30 degrees C, the risk for dysrhythmias increases

Rewarming and Management

Type of rewarming is based on cardiovascular status, NOT temperature
Passive rewarming: removal from cold environment and wet clothes, insulation
Active external rewarming: warm water immersion, heating blankets set at 40 degrees C, radiant heat, forced air
Active core rewarming at 40 degrees C: Inhalation rewarming (warm air via the vent), heated IV fluids, GI tract lavage, bladder lavage, peritoneal lavage, pleural lavage, extracorporeal rewarming, mediastinal lavage by thoracotomy
Remember to handle these patients gently to avoid precipitation of ventricular fibrillation!

ECMO in Hypothermic Arrest

The use of ECMO has been recommended as the rescue therapy of choice for hypothermic cardiac arrest for its ability to rapidly rewarm patients (8-12 degrees/hour) and provide complete cardiopulmonary support
Studies have shown that patients with cardiac arrest have a rate of survival of 50% with the use of ECMO, whereas, at centers without ECMO, these same types of patients have a survival rate of only 10%
Cases of survival with a good clinical outcome have been reported with core temperatures as low as 13 degrees Celsius and in cases requiring long transport with more than 5 hours of CPR!

Risk Factors for Poor Prognosis Despite Aggressive Therapy (ECMO, etc):

Clear history of cardiac arrest before cooling
Obvious signs of irreversible death
Core body temperature higher than 32 degrees Celsius with asystole
Potassium greater than 12 mEq/L

Friday Board Review

Pediatrics Board Review with Dr. Edward Guo

December 8, 2023December 3, 2023 Edward GuoLeave a comment

A 13 year old male presents to the emergency department for 2 days of abdominal pain and diarrhea. He has no past medical or surgical history other than a tooth extraction for which he recently completed a week of clindamycin. The abdominal pain is generalized and associated with greater than 5 episodes of watery diarrhea daily. He denies any vomiting or recent travel. Vitals signs are: HR 120, BP 108/60, T 38.3 C, RR 20, SpO2 99% RA. On exam, he is tired but non-toxic appearing and not in acute distress. Mucous membranes are dry, and his cap refill is between 2 to 3 seconds. His abdomen is minimally tender to palpation diffusely with no guarding or rigidity. IV access is obtained and fluid resuscitation is started. What is the appropriate antibiotic treatment for this patient’s suspected condition?

A: IV vancomycin and cefepime

B: PO metronidazole

C: PO vancomycin

D: PO vancomycin and IV metronidazole

Answer: PO metronidazole

This patient’s fever, abdominal pain, and profuse diarrhea in the setting of recent antibiotic use is worrisome for Clostridium difficile (C. Diff) infection. Oral metronidazole is the treatment of choice in mild to moderate cases of pediatric C. Diff colitis. It is first-line due to being less expensive than vancomycin and avoids the potential risk of developing vancomycin-resistant enterococci. IV vancomycin and cefepime are broad spectrum agents commonly used in sepsis but are not preferred for suspected C. Diff colitis. In addition, the combination lacks anaerobic coverage for gastrointestinal infections. PO vancomycin with or without IV metronidazole is reserved for recurrent or severe infection which includes hypotension, ileus, or inability to tolerate PO antibiotics.

Pediatric Clostridium Difficile Colitis Treatment
All patients	Fluid resuscitation and electrolyte repletion Discontinue offending antimicrobial agents if possible
Mild to moderate disease	PO metronidazole
Severe disease	PO or rectal vancomycin + IV metronidazole

References:

Freedman S.B., & Thull-Freedman J (2020). Vomiting, diarrhea, and dehydration in infants and children. Tintinalli J.E., & Ma O, & Yealy D.M., & Meckler G.D., & Stapczynski J, & Cline D.M., & Thomas S.H.(Eds.), Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw Hill.

Thursday Conference Content & EKG Review

Bronchiolitis by Dr. Sandy Nairn

December 7, 2023December 1, 2023 John CafaroLeave a comment

Wednesday Image Review

From the Archives: What’s the Diagnosis? By Dr. Becca Fieles

December 6, 2023December 3, 2023 Edward GuoLeave a comment

A 30 year old female with a history of IV drug use presents with 2 weeks of progressively worsening right sided pleuritic chest pain, productive cough, and shortness of breath. A chest x-ray is shown below. What’s the diagnosis?

Answer: Cavitary lesion with air-fluid level consistent with abscess from septic emboli secondary to infective endocarditis

Etiology: Bacteria laden clots from right sided bacterial endocarditis, septic thrombophlebitis, periodontal, and central venous catheter infections. In IVDU, the tricuspid valve is most commonly involved with the most common pathogen being Staph aureus

Presentation: Pleuritic chest pain, cough, fever, hemoptysis

Differential for lung abscesses: Septic emboli, Tuberculosis, Aspergillosis, Granulomatosis with Polyangitis, Sarcoidosis, malignancy

Diagnosis: Chest x-ray, CT chest, blood cultures, echocardiogram

Treatment: Typically 2-8 weeks of IV antibiotics with possible abscess drainage +/- heart valve replacement

References:

Stawicki SP, Firstenberg MS, Lyaker MR, et al. Septic embolism in the intensive care unit. Int JCrit Illn Inj Sci. 2013;3(1):58-63. doi:10.4103/2229-5151.109423

Parkar AP, Kandiah P. Differential Diagnosis of Cavitary Lung Lesions. J Belg Soc Radiol.2016;100(1):100. Published 2016 Nov 19. doi:10.5334/jbr-btr.1202

Tuesday Advanced Cases & Procedure Pearls

Critical Cases – Central Vertigo!

December 5, 2023December 5, 2023 Richard ByrneLeave a comment

Submitted by Rahul Gupta M.D.

HPI

43-year-old female p/w sudden onset vertigo, nausea, vomiting, and severe R sided headache 1 hour PTA
HA is R sided, radiates into neck
No weakness, numbness, tingling, speech changes
Pt notes balance issues
States that the vertigo is positional in nature.

Physical Exam

Vitals: BP 210/89, P 75, RR 18, SPO2 98%

Neuro exam: Cn II-XII intact, motor strength normal, normal finger to nose, no nystagmus noted
Gait was unable to be assessed secondary to vertigo

DDx

subarachnoid hemorrhage, posterior circulation stroke, primary headache, vertebral artery dissection, peripheral vertigo

Case course

A stroke alert was called
CTA Head and neck demonstrated R vertebral artery occlusion. MRI demonstrated an acute infarct of the cerebellar vermis.

Pearls:

Initial work-up of vertigo is stratifying between central and peripheral vertigo. The below table provides general patterns for both, but this is variable in nature.

HINTS exam should be performed only when patient has persistent vertigo, nystagmus, and a normal neurological exam. When used correctly and performed appropriately, the HINTS exam has impressive sensitivity (100%) and specificity (96%) for posterior circulation stroke as compared to MRI
See the HINTS exam in action here:

The Dix-Hallpike maneuver can be performed if BPPV is in the differential. Dix-Hallpike is only 50-85% sensitive for BPPV. If positive, consider the Epley Maneuver for treatment.
- Consider teaching the patient the maneuver if they find relief after the Epley maneuver.
- Other treatments for peripheral vertigo include:
  - 1^st line: Diphenhydramine 25-50mg IM/IV/po q4hr, Meclizine 25mg po QID
  - 2nd line: Diazepam 2-10 mg po/IV q4h-q8h, Lorazepam 0.5-2mg po/IM/IV q4h-q8h

References

Barraclough K, Bronstein A. Vertigo. BMJ. 2009;339:b3493
Kuo CH, Pang L, Chang R. Vertigo – part 1 – assessment in general practice. Aust Fam Physician. 2008;37(5):341-7
Newman-Toker, D. E., Kattah, J. C., Alvernia, J. E., & Wang, D. Z. (2008). Normal head impulse test differentiates acute cerebellar strokes from vestibular neuritis. Neurology, 70(24 Pt 2), 2378–2385. https://doi.org/10.1212/01.wnl.0000314685.01433.0d
Sacco RR et al. Management of Benign Paroxysmal Posi- tional Vertigo: A Randomized Controlled Trial. J Emerg Med. 2014 Apr;46(4):575-81