Friday Board Review

Board Review with Dr. Edward Guo

Edward GuoLeave a comment

A 19 year old male with no past medical history is brought in by EMS due to a report from his college roommate for strange activity. Over the last week, the patient has skipped all of his classes and barricaded himself in his room. He states that the FBI is tracking him and plan to kidnap him. Vitals are within normal limits. Exam shows a disheveled appearing male. He eventually attempts to run out of the emergency department but is tackled by security. Verbal de-escalation is not successful. Which of the following intramuscular medications is contraindicated for the management of this patient? 

A: haloperidol

B: ketamine

C: lorazepam

D: olanzapine

Answer: ketamine

This patient presenting with disorganized behavior and paranoid delusions is concerning for an acute psychotic episode. Ketamine is an agent commonly used for sedation that is absolutely contraindicated in patients with known or suspected schizophrenia even if it is currently well controlled due to the risk of emergence reactions and worsening psychosis. Haloperidol, olanzapine, lorazepam are agents commonly used for the management of acute psychosis and agitation.

Ketamine for Procedural Sedation or Agitation
ContraindicationsAllergy to drug
Age < 3 months old
Known or suspected schizophrenia
Dosing1-2 mg/kg IV
4-6 mg/kg IM
Adverse effectsLaryngospasm or apnea associated with rapid push
Nausea & vomiting
Emergence reaction

References:

Ali S, & Poonai N (2020). Pain management and procedural sedation for 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.

Myers J.G., & Kelly J (2020). Procedural sedation and analgesia in adults. 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.

Wilson M (2020). Acute agitation. 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.

Wednesday Image Review

What’s the Diagnosis? By Dr. Kane McKenzie

Edward GuoLeave a comment

A 78 year old female presents to the ED from a cardiac rehabilitation facility with increasing shortness of breath and a productive cough. She was discharged from the hospital two weeks ago after having a coronary stent placed which was complicated by pneumonia and developing heart failure. She was discharged on PO amoxicillin-clavulanate. Vitals are notable for a heart rate of 101 and are otherwise within normal limits. 

Labs are remarkable for an elevated WBC of 18.55 and elevated NT-ProBNP of 2155. Point-of-care cardiac ultrasound shows a normal ejection fraction. Right sided point-of-care lung ultrasound findings are shown below. What’s the most likely diagnosis, and what pathognomonic ultrasound “sign” is seen?

Answer: Pneumonia; Hepatization of the lung

  • Normally, lung is not well visualized on ultrasound because the alveoli are filled with air which does not transmit ultrasound beams well to produce an image.
    • Aerated lung will produce horizontal “A lines”, a reverberation artifact from the result of sound waves bouncing between the skin and pleural line.
  • With consolidation of the lung or pneumonia, ultrasound beams are able to travel through the purulent or fluid filled alveoli.
    • The lung will appear hypoechoic and heterogeneous, resembling the liver, hence the term “hepatization of the lung.”

References:

Dawson M, Mallin M. Introduction to Bedside Ultrasound: Volume 1. Emergency Ultrasound Solutions; 2013. 

Durant A, Nagdev A. Ultrasound detection of lung hepatization. West J Emerg Med. 2010;11(4):322-323

https://litfl.com/lung-ultrasound-pneumonia/

Tuesday Advanced Cases & Procedure Pearls

Euglycemic DKA by Dr. Sarah Perelman

Edward GuoLeave a comment

A 45 year old male with a history of alcohol use disorder, diabetes on insulin, glipizide, and empagiflozin presents with chest pain and shortness of breath. 3 days ago, he drank 20 beers and then started vomiting. Last night, he developed chest pain and headache. Today, he has been feeling short of breath.

Vital signs: BP 126/70, HR 90, Temp 98.7F, RR 35, SpO2 99%. EKG is normal. Accucheck 182.

On exam, he is generally uncomfortable appearing and tachypneic with increased work of breathing. He has dry mucous membranes and clear lung sounds bilaterally. There is mild tenderness to palpation over the epigastric area.

Labs are notable for:

  • VBG: pH 7.08, pCO2 20, HCO3 9
  • BMP: Na 121, BUN 23, creatinine 1.12
  • Ethanol, salicylates, and acetaminophen levels undetectable
  • Lactate 1.3
  • Beta-hydroxybutyrate 9.8
  • Urine: 4+ ketones, normal specific gravity

Differential diagnosis includes: Euglycemic DKA, Alcoholic Ketoacidosis, Starvation Ketosis, and Toxic Alcohol Ingestion

Management:

  • Started with 1L NS bolus  
  • Insulin infusion @ 0.1 u/kg/hr 
  • Thiamine, folate supplementation 
  • GMAWs protocol for expected alcohol withdrawal 
  • Critical Care consultation

Pearls: 

  • Symptoms of acidosis: nausea, vomiting, headache, abdominal pain, generalized weakness, Kussmaul respirations (tachypnea with belly breathing and clear lungs)
  • Differential diagnosis for anion gap metabolic acidosis: uremia (high BUN/creat), lactic acidosis (sepsis/shock), ketoacidosis (DKA vs. alcoholic vs starvation), ingestion (salicylate vs. acetaminophen)
  • Euglycemic DKA: a rare disorder in which glucose level is relatively normal (<250) but ketoacidosis develops
  • Consider eDKA in pregnancy, type 1 diabetes, alcohol abuse, liver failure, starvation, but most notably in patients taking SGLT2 inhibitors (-“flozin”)
    • Treatment: D5NS + insulin, replete K if needed 
  • Euglycemic DKA and alcoholic ketoacidosis can be very difficult to distinguish, as alcohol use and poor PO intake can precipitate euglycemic DKA. In anyone with diabetes presenting like the case above who is on an SGLT2 inhibitor and impaired liver function, have a low threshold to start insulin to help drive the glucose into cells once glucose >180.

References:

Gabor, KD., Cline, DM. “Acid-Base Disorders.” Tintinalli’s Emergency Medicine a Comprehensive Study Guide, 9th Edition.” (73-78).

Howard RD, Bokhari SRA. Alcoholic Ketoacidosis. [Updated 2021 Dec 12]. StatPearls. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK430922/

Mehta, A., Emmett M. “Fasting Ketosis and Alcoholic Ketoacidosis.” UpToDate. October, 2020.

Nyce, A. Byrne, R., Lubkin, C. Chansky, M. “Diabetic Ketoacidosis.” Tintinalli’s Emergency Medicine a Comprehensive Study Guide, 9th Edition.” (1433-1441).

Friday Board Review

Board Review by Dr. Hilbmann (Edited by Dr. Parikh)

Vidhi ParikhLeave a comment

A 34-year-old male with past medical history of asthma and major depressive disorder presents to the emergency department with fever, tachycardia, and right lower extremity pain and swelling. The patient was recently hospitalized for an asthma exacerbation where there was a reported MRSA outbreak. Physical examination is concerning for cellulitis of right lower extremity. Home medications include albuterol and phenelzine. Patient reports an allergy to vancomycin which results in anaphylaxis. Which of the following antibiotics should be avoided when treating this patient’s infection?

A. Daptomycin

B. Linezolid

C. Ceftaroline

D. Trimethoprim-Sulfamethoxazole

Answer: B.

This patient is on a home medication of phenelzine, an antidepressant which belongs to the Monoamine Oxidase Inhibitor (MAOI) class. MAOIs are associated with tyramine reactions, serotonin syndrome, and other medication incompatibilities. It is not only important for emergency medicine physicians to be able to recognize the presentation of the complications of this drug class, but also not to cause a harmful reaction themselves. Emergency medicine physicians should not administer meperidine, dextromethorphan, linezolid, tramadol, propoxyphene, selective serotonin reuptake inhibitors (SSRIs), or selective serotonin-norepinephrine reuptake inhibitors (SSNRIs) to patients on MAOIs due to risk of inducing serotonin syndrome. Emergency medicine physicians should be monitoring for clonus, hyperreflexia, tremor, seizures, agitation, pressured speech, or autonomic instability in all patients on MAOIs. Treatment of serotonin syndrome involves cessation of the affected drug, cyproheptadine, hydration, cooling, and benzodiazepines for seizure management.

Patients should avoid when taking MAOisPrescribers should avoid when patients taking MAOis
WineMeperidine
CheeseDextromethorphan 
CocaineLinezolid
MDMATramadol
Propoxyphene
SSRIs
SNRIs

Resources:

Flockhart DA. Dietary restrictions and drug interactions with monoamine oxidase inhibitors: an update. J Clin Psychiatry 2012; 73 Suppl 1:17.

Tintinalli, J., Ma, O., Yealy, D., Meckler, G., Cline, D., Thomas, S. and Stapczynski, J., 2020. Tintinalli’s emergency medicine. 9th ed. [New York]: McGraw-Hill Education, pp.1204-1208.

Wednesday Image Review

What’s the Diagnosis? By Dr. Daniel Petrosky

Edward GuoLeave a comment

A 44 year old woman with a past medical history of kidney stones and diabetes presents to the ED with 3 days of intermittent flank pain for which Tylenol is not helping. On exam, she is crying and in pain with some tenderness in RLQ and suprapubic area. No CVA tenderness noted. She denies fever and dysuria. A CT abdomen and pelvis with IV contrast was obtained and shown below. What’s the diagnosis?

Answer: bilateral emphysematous pyelonephritis (Findings: bilateral xanthogranulomatous pyelonephritis. Right perinephric stranding. Gas within both renal collecting systems and urinary bladder.)

This is a severe necrotizing infection of the kidney parenchyma. Primarily, cases occur in those with uncontrolled diabetes (95%) and a secondary factor is kidney obstruction (25-40%). The usual bacteria involved is E. Coli (69%) or K. Pneumoniae (29%). If caught early medical management of kidney function and antibiotics is the primary mode of treatment. Failure of initial treatment can lead to a nephrectomy.

  • Class 1: gas in the collecting system only
  • Class 2: gas in the renal parenchyma without extension to extrarenal space
  • Class 3A: extension of gas or abscess to perinephric space
  • Class 3B: extension of gas or abscess to pararenal space
  • Class 4: bilateral EPN or solitary kidney with EPN

Management: admit for IV antibiotics and urological consult

This particular case has Proteus as the infective species as evident by staghorn calculi and urine culture. Because of preserved kidney function (Cr 0.87) and WBC (4.45), Urology elected to monitor and treat infection first and schedule outpatient procedure for stone removal to prevent urosepsis.

References:

Huang JJ, Tseng CC. Emphysematous pyelonephritis: clinicoradiological classification, management, prognosis, and pathogenesis. Arch Intern Med. 2000 Mar 27;160(6):797-805. doi: 10.1001/archinte.160.6.797. PMID: 10737279.

Ubee SS, McGlynn L, Fordham M. Emphysematous pyelonephritis. BJU Int. 2011 May;107(9):1474-8. doi: 10.1111/j.1464-410X.2010.09660.x. Epub 2010 Sep 14. PMID: 20840327.

Tuesday Advanced Cases & Procedure Pearls

Metformin Overdose by Dr. Eugene Marrone

Edward GuoLeave a comment

51 y/o male with a PMH of DM presented with an out of hospital cardiac arrest after a suicide attempt, found to have a lactate of 26.9, bicarb of 3, and pH <6.8. After collateral from the family, it was found that he overdosed on metformin. 

METFORMIN OD:

Precise amount of metformin required to do this is unclear, but seems to be high (e.g., >20 grams). The main effect of metformin is inhibition of the mitochondrial transport chain complex-I, which essentially poisons the mitochondria.

Presentation: 

  • Vitals: The following abnormalities may be seen:
    • Hypothermia
    • Hypotension progressing to vasopressor-refractory shock can occur
  • GI symptoms often predominate: Nausea, vomiting, diarrhea, epigastric pain.
  • Delirium, decreased consciousness.

Management:

  • Supportive care, can consider bicarb 
  • Hemodialysis! Main indications:
    • Lactate >15-20 mM
    • pH <7.0-7.1
    • Failure to improve despite standard supportive measures

References:

Calello DP, Liu KD, Wiegand TJ, Roberts DM, Lavergne V, Gosselin S, Hoffman RS, Nolin TD, Ghannoum M; Extracorporeal Treatments in Poisoning Workgroup. Extracorporeal Treatment for Metformin Poisoning: Systematic Review and Recommendations From the Extracorporeal Treatments in Poisoning Workgroup. Crit Care Med. 2015 Aug;43(8):1716-30. doi: 10.1097/CCM.0000000000001002 [PubMed]

Wang GS, Hoyte C. Review of Biguanide (Metformin) Toxicity. J Intensive Care Med. 2019 Nov-Dec;34(11-12):863-876. doi: 10.1177/0885066618793385 [PubMed]

https://www.extrip-workgroup.org/metformin