Emu Sept 2013 Part 2

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EMERGENCYMEDICINE UPDATE

1)operations. They did admit them for IV antibiotics with Tazobactamand PCN and it hey did well- discharge with Cipro and Metronidazole.

(WJS 36(9) 2028) Only problem here is that it was not randomized.Patients choose what they wanted. Further more- did they really needTazo? TAKE HOME MESSAGE: Antibiotics should be first line in

appendicitis- perhaps2)Do not really know the answer to this, but it will piss some folks off.

California passed a law regulating how many patients can be treatedby one nurse. As such, more nurses are now working in hospitals and

the ratio of patients to nurses has come down. However on the quality

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indicators of post operative sepsis and respiratory failure there hasbeen no measurable difference before the new law and after (Health

Serv Res 48(2)435) What the article did not mention is that respiratoryfailure does poorly no matter what, and post operative sepsis may be apoor indicator- that could be due to surgical technique, OR sepsis or

surgeries with high rates of sepsis no matter what. Greg Henry hasgone on record on EM RAP saying that in the ED we do not need

nurses- the work can be mostly taken care of by techs just likephysicians assistants can do the work of an MD- AND THEY ARECHEAPER! What do you think? TAKE HOME MESSAGE: More nurses

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with less patients duties did not result in improved

quality

3)You really do not have to read EMU just sum it up as "everythingyou were taught was wrong". And I'll prove it. Use of FFP has not

therapeutic benefit in 80 + trials of its use. Now they agree the qualityof trials has not been the greatest- but when are we going to do goodwork and get the answers? (Transfusion 52(8)1673) Yes let me repeat

it- it doesn't work for coumadin reversal. OK, let me put my two cents

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in it does get the INR down to 1.5 but that in many cases will notstop the bleeding. Interestingly enough- many of these studies were

not done for INR excess but rather as treatment for snake bites,Myastenia and dengue. BTW, EM RAP also tried to slay another sacredcow by dissing Kexylate as been never proven to work and being

dangerous- hey EMU reported on this way back in 2005. I likefurosemide as a good treatment if the patient can urinate. Dialysis is

always the best bet for CRF. TAKE HOME MESSAGE: FFP may not work

use PCC instead.4)This was not a very interesting article- but then again, is anything in

EMU? but just to remind you- if you are going to inject a joint-remember that Depo Medrol has a half life of 1.8-2.2 days, Kenalog

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3.2-6.4 days and Celestone 6.3 days. ( J Hand Surg Am 37(8)1718)

5)Let's talk kids for the next two paragraphs- firstly we'll give you some

ideas for infantile colic. Let's

face it- we do not know what the cause of it is and the kids aren't

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talking. First of all the red flags.Apneic episodes, cyanosis, vomiting, respiratory distress, and bloodystools. Even if you are an internists (which you probably aren't becausethey would not have read this far into this) you would pick this up. Justremember intussusception and pyloric stenosis as causes. Also, largeheads, hypotonia, petechia or low weight or any signs of sepsis (keepin mind maternal fever from group B strep in the Mom can causeneonatal fever). Second important point - - you generally do not need

blood tests or x rays if the history is unrevealing. Here is their list: UTI,

meningitis, otitis, constipation, cow's milk allergy, GERD, hernia analfissue, inborn errors of metabolism (oh, I hate those) hypoglycemia,

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hydrocephalus, trauma, abuse. Here is my list: consider also cornealabrasion (this happens a lot), constipation and the ever popular-

diaper rash. Treatment. Well, the obvious is obvious, but if we arespeaking of cow's milk- use a formula that is completely hydrolysed.Replacing it with soy is not done anymore it is allergenic. A

hypoallergenic diet (no peanuts, fish etc) in moms who breast feedmay help just make sure the kiddies get enough calcium and vitamn

D. Lactase supplementation may not help. Simthecone doesn't help- orhurt either. Diclycimine and Cimetropium do help and do hurt as well-the side effects limit their use. They speak about all sorts of

complementary therapy including chiropractic (chiropractic???) onlypro biotics have shown any promise. If you are a European- you may

know what gripe water is- it doesn't work either. (BMJ 347.14012)TAKE HOME MESSAGE: Infantile colic- see list above. Do not do tests

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or films unless really indicated. Gripe water- give it to those who gripe.

Not kids.6)Really nothing new here, but we have new subscribers all the time

this is an executive summary of pain control in kids and I liked that thedivvied it up into types of pain and quality of evidence. Here are the

keys that you all knew already or should know- or at least will know-or maybe not care about. Breastfeeding during the procedure- lowerspain (in infants, silly). Sucrose helps as well. Use EMLA when you can.

Do not take blood through heal sticks- use a vein if at all possible.Vapocooling may help (like Ethyl Chloride). Even if you anesthetize the

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skin, a suprapubic aspiration hurts more than a catheterization. Usenitrous oxide for LPs in kids able to handle it. Buffer your lidocaine-

which we all know but never do, probably because it comes in bigbottles and you waste most of the bottle. Consider closing headlacerations by the HAT technique which is simply tying two pieces of

hair together on each side of the laceration and pulling taut. Aftertonsillectomy be liberal with lidocaine spray. Use bupivicaine when

possible, use nerve blocks when possible. That is all. (Ped Anesthesia22:1-79s) TAKE HOME MESSAGE: Kids do need adequate pain control

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and here are some tips- read the rest of the paragraph, big guy and be

a better man for it.7)I am not a woman, and like most guys, we do not really understand

them that well. Actually, at all. We do however, want to help themwhen they come as our patients, but their genitalia are mostly internal

and because of our lack of understanding, we end up doing painful,uncomfortable and futile pelvic exams. So how do we get better at

this? Well, I was always embarrassed to say I learned on women who

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where under anesthesia for an operation as was told to do so by myattending. Well, apparently I wasn't alone. Many physicians learn this

way. And there is a word for it A crime (or in legal language-battery.) Ask your patients- only 19% have any thought that theywould be examined in the OR by a medical student. Most of the time

there is no consent and in awake patients: no introduction to thepatients that the one examining them is a medical student. I am still

embarrassed by this way of learning and believe strongly that iswrong. (CMAJ 184(10)1159) The solution is so easy- just get the darnconsent. Learning is important. But respecting a person as a person

and understand the license to help them that you have been granted is

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even more important. TAKE HOME MESSAGE: I have said enough.

What do you think?8)I really think that the FP's literature should be up to the standards of

all specialties but the authors of this how to paper on treating kidneystones obviously doesnt read EMU. Listen guys- we do not do anabdominal film to look for stones, we do not give antispasmodics; and

alpha blockers have been disappointing. Fluids may actually increasethe pain through spasm. Now it pays to remember the causes of

stones including IBD, gout, bowel surgery, obesity DM

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hyperparathyroidism see #1 above- D'oh and CRF. Most stones arecalcium oxalate and are favored by an acid urine. Check the urine for

a 24 hour phosphorus, magnesium, calcium, uric acid and citrate(which is an inhibitor of stone formation). Catching the stone? Reallyrarely happens. However a good point is increased fructose

consumption predisposes to more stones- in the USA they use that alot for sweetener. (AFP 84(11)1234) TAKE HOME MESSAGE: Good

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chart here for workup in preventing stones but the treatment is still

the same.

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9)This is one of those everything you wanted to know but were sorry

you asked . There are four types ofnonconvulsive status eplipticus. Absence, simple partial (patientawake, but somatosenosory symptoms or even hallucinations) complex

partial (most common-they have altered mental status) and subtle (themost malignant). The latter is common in the ICU perhaps in as highas 48% of the patients. Diagnosis is often tough- of course (see D'oh

above) but if the patient doesn't wake up an hour after a regularseizure- he might still be seizing- a little tough for me to swallow that-

an hour of frying the brain doesnt seem healthy. The treatment is thesame as for regular status, but consider continuous propofol or

ketamine for those tough to stop cases. Really stuck? Consider deepbrain stimulation or hypothermia (Curr Treat Op Neuro (14:307) TAKE

HOME MESSAGE: no new treatment options, but do not forget non

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convulsive status for comatose patients.

10) Here is the mail for this month. Firstly from Dr. Axel who

commented on Farrah Fawcet Majors She is not a blonde. She is not abeauty.As far as pretty is concerned, Axel, if I am correct- you arefrom France and one cannot compare a country that gave us a fashion

standard in Coco Channel to the USA whose fashion statement is mostprobably Lady Gaga. As far as a real blonde is concerned, I didn't

know that she was a fake (gosh, I am crushed) but let me in on anunpublished study below. BTW, I have no blonde fixations (although

Randall Powell might) but I do not control the mail I receive, and Iknow we discussed blondes above in 11 and 12.

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completely normal.) As usual, comments that are helpful and useful. I couldnot have said it better. The comment on standardized tests real demands we

make a major change in our education system. What do you think?11) Answer to number five- that was AL Lewis in the comedy series-

the Munsters. And number twelve was the Swedish singing group

ABBAThey stop recording together in 1982- but they still get togetherevery once in a while

EMU LOOKS AT:Iron and Sirens (in the head)This month we look at two interesting (come on after 37 pages what

could be possibly interesting?) (Will you be quiet already so we can getthis over with?) (Well, I am just telling the truth) (But no one asked you)subjects. Let's get straight to them (good, you wasted enough time

already) (again you making peole nuts?) (No, you are- who cares aboutwhat you write here?)(Well Chris Nickson does) (He is down in Australia,

come on they don't even play real football) (No one in the world does

except for USA and Canada) (You gonna mess with these guys?)

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) The sources for

thieve articles are PEC 27(10)978) and Clin Ob Gyn 55(3)810).IRON POISONING1)Officially this article is about kids, but the principles are the same ( and

that which I held back and didn't day that kids are just little a)(There you said it anyhow you pompous internist) (I am not an

internist) (you act like one). Just remember, that the key in ironpoisoning is knowing how much elemental iron was ingested not theamount of iron compound, For example, Ferrous sulfate only contains

60 mg of elemental iron despite having a dosage of 325mg. Ferrousfumarate has 10 mg. Ferrous gluconate has 36mg. Carbonyl iron has

45. Children's multivitamins have up to 20 mg and adult's up to 50.Prenatal have the most-up to 100mg. Important to note that there areno reports in the literature of fatalities from children's multi vitamins. I

will point out that this means no fatalities- but injury or poisoning can

occur. Prenatal and adult MVIs are more dangerous to kids. The

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existing guidelines allow for home observation of children'smultivitamin ingestions that are asymptomatic.

2)Severe toxicity is seen at 60mg/kg of elemental iron. 10 mg/kg cancause symptoms of toxicity. Less than this is usually safe.

3)And now the moment you have been waiting for- the classic four

phases of iron poisoning. Phase one is the acute injury. Thesesymptoms can be non specific but are usually GI- nausea, vomiting

and GI bleeding that can be upper or lower. However, even saferdosages such as 5 mg/kg can cause some diarrhea. If the patient doesnot display any signs of poisoning during this six hour period, the

likelihood of serious ingestion is extremely low.4)Phase two is the latent period- and is from 6- 24 hours after ingestion.

Here there is continuing cellular toxicity and organ damage, but someof the GI symptoms might improve. But then again they may not. And

even if they do improve- it is never completely. Metabolic acidosis maydevelop here.

5)Phase three. This can start anytime and can be earlier with higher

dosages. Here there are signs of shock and - coagulopathy, acidosis,negative inotropy but no affect on vascular resistance. Coagulopathy

occurs even if the liver is not affected.

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6)Phase four is within two days and here the liver is the target,.

This usually requires an iron

level of greater than 1000. Actually, it doesn't happen that often.7)Phase five is the recovery. There can be fistula, strictures and internal

scarring. Gastric outlet syndrome is common because of the damage

done at the pylorus due to the tablets that congregate there. All in all a pretty lousy way to go.

8)Testing: here you need to go with the iron level. Concerning shouldbe levels above 300 mcgs. But do this measurement after four

hours. WBC, glucose not relevant. And yes- neither is TIBC-manyreasons for this but let's not get to involved. Abdominal films canshow the pills to help guide WBI, but a negative film doesn't help you

at all.9)Here are your choices for treatment- pay close attention. Cathartics-

don't work. Calcium Disodium EDTA- used for lead poisonng- doesn'twork. Bicarb no help here unless there is a bad metabolic acidosis.

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(I don't believe it helps there either). Oral Phosphates- no help hereeither. Magnesium didn't help but Kexylate did seem to help but it was

a poor study. Lavage well, no one is supposed to do this anymore. Itcan get out a lot of the pills, but it can push them further down thetract. WBI whole bowel irrigation- is recommended- it is probably

the best idea in an acute ingestion but surprisingly has only beenshown to work in case studies. Give a nine month old- to six years-

500 cc, 6-12 1000 per hour and 13 adult- 2000 ml/hr until cleareffluent. Charcoal will not help.

10) Deforaxamine is the treatment. This chelates free iron and sends

it out the door in the urine imparting a pleasant vin rose color to theurine. Please do not mix this up with real wine; we do not want it to

get to the Wine of the Month series. It will not help for iron bound tohemoglobin, hemosiderin, transferrin or ferriten. You can give this stuff

IV or IM, and the dosages are as follows. IM it is 50mg/kg every sixhours up to a dosage of 6 gm a day. IV is 15mg/kg for an hour, than125 mg/hr. However IV is way more effective. In an emergency, giving

50 mg/kg per hour is probably safe. You give it until the urine turnsclear again. Following serum levels of iron is not dependable for

treatment purposes. This drug is not without dangers. Giving it too fastcan cause hypotension, renal failure can happen, although mostrecover. ARDS can also happen but this is thought to be from infusions

that were for long periods of time. Try to limit treatment to 24 hours.Yersinia likes iron to help it grow and there can be Yersinia sepsis

when this med is given. Are you pregnant, mate? Well you can havethis med it doesn't cross the placenta. This stuff works also for

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aluminum toxicity. It may chelate the stuff you use to turn your hairblonde

11) Oral chelation doesn't work- yet- there are some things on thehorizon. Iron is not dialyzable, but the iron desforoxamine complex is.Plasmophoresis should theoretically work and in one case-was

wonderful. Intralipid works for a lot of things- not sure if for this. Andlastly an animal study showed that valium reduced morality without

chelation. They do not know the mechanism but I am sure it has to do

with them being happier

Neuro in PregnancyThis is a rare review article on the subject and you should realize pregnancycan complicate things considerably. Let's start with the most common

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1)Headache. This is present in 35% of pregnancies. Well let's make thisinto a quiz. Give the most common headache that fits each below.

a) Most common headache

b) Mnemonic POUND

(Pulsatile, one day duration, unilateral, Nausea, Disabling)

c) Comes from use of pain relievers

d) Can have photophobia but no neural or autonomic symptoms

e) Increase in muscular tension

f) Associated with autonomic symptoms such as lacrimation and

rhinorrhea

g) Occurs after consumption of >200mg of caffeine steadily for no less

than a month,

h) Caused by vessel dilation under the dura materDepletion of serotonin along neural pathways and hormonal

fluctuations

i) Greater chance of low birth weight and preeclampsia

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A)MigraineB)Tension Headache

C)Withdrawal headache/rebound headacheD)Cluster headacheE)None of the above

2)Are you crazy? I 'm not giving you the answers!3)This is all fine if your pregnant patient comes in with a headache

history but often it is the first time and you must rule out bleed,pregnancy induced hypertension and pre eclampsia. These probablymake up 33% of all new headaches in pregnancy. Secondary

headaches in pregnancy occur frequently with fasting or starvationbeing common causes (Hyperemesis). Other causes in the pregnancy

period include stroke, sinus vein thrombosis, pseudotumor, andpituitary apoplexy. Let's look into the dangerous headaches of

pregnancy a little deeper4)Pre eclampsia- really can't tell you anything new here that you do not

know. Protein in the urine, relative hypertension (140/80) and of

course bad headaches. SAH is not clearly increased in pregnancy, butis in the puerperium. Cortical vein thrombosis is a form of stoke which

is specific to pregnancy. They can have HTN and neuro deficits ofcourse, but also nausea, papilledema and altered mental status. Keepthis in mind as they often are mistakenly diagnosed as pre eclampsia.

Pseudo tumor does not occur more in pregnancy but it gets worse. Itis a daily pulsating headache worse upon position change.

5)Diagnosis- also nothing new here. CT is CT with all the radiation risks(about 5- 10 mSV) but one CT will not cause fetal loss, fetal

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abnormalities or more leukemia. Shielding probably makes it even lesslikely. Iodianted contrast doesnt get into breast milk in sufficient

quantities to affect neonates. So if you have to-just do it.

6) MRI is fine as is the use of gandolinium.7)Treatment- tell them to get some sleep even though they have

another human kicking them in the ribs all the time. Exercise helps aswell. NSAIDS are OK up too 30 weeks. Aspirin seems to be good allthe time- never have seen any negative effects on the PDA with

Aspirin. Paracetomol is of course OK, Optalgin- nothing to report here,but you can give phenothiazines and ondansetron. Steroids were

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thought to cause cleft palate- but if it does happen it is rare. Triptansseem to be OK; but only sumatriptan has earned a C category. As

usual avoid opiods and erogtamines as well. Anticonvulsants areteratogenic.

8)On to other neuro problems in pregnancy. Firstly CP. These folks often

have epilepsy, bladder dysfunction, HTN GERD and osteopenia. Therefore they have multiple issues- the mutagenic effects of the anti

convulsants, worsening GERD and constipation, more pylo andspasticity. Similarly, women can have spinal cord injury and still getpregnant. Just remember that if the lesion is above T6 they can have

ADR- autonomic dysreflexia noxious stimuli from under the spinallesion can lead to headache, nausea, sweating and runaway blood

pressure. Noxious stimuli include IUDs, distended bladders, vaginalexams, PID and UTI, and labor and even breast feeding. ADR can

lead to maternal intracranial bleeds and fetal distress. Also, spinalcord inuries and CP may not feel the contractions of labor. A thirdsimilar problem is MS, and 1/3 of women will have a flare during

pregnancy.9)So what can you do? Vaccinate, work with the PT services, and give

folic acid to those taking anti convulsants. Spasticity will worsen inpregnancy. Use glycopyrolate for anticholenergic effects. Patients'need to know how to indentify pre term labor. ADR versus

preeclampsia-ADR shows elevated blood pressure in a patternmimicking contractions where as in pre eclampsia; symptoms are

irrespective of contraction patterns. Not really sure what that means

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10) Bell's palsy mostly occurs in the third trimester. Justremember Ramsey Hunt, Lyme, stroke, cholesteatoma, mumps and

Myasetenia Gravis. Steroids are the generally way to go11) Well, maybe I will give you the answers anyway to the head

ache questions, but I think you all knew them. The answers to

headaches- a-B, b-A, c-C, d-B, e-E,f-D,g-C,h-A,i-AHey a great New Year for all our Jewish readers! May we see peace

worldwide!

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Emu Sept 2013 Part 2