Patients requiring anticoagulation for HIT or with a history of HIT may be initiated on argatroban.  We have recently been seeing increased utilization.  Here are some important points to remember.

• MOA: Direct thrombin inhibitor – reversibly binds to the active thrombin site of free and clot-associated thrombin
• Monitoring parameters:
  • aPTT prior to starting therapy (similar to heparin)
  • aPTT two hours after initiation of therapy or after dose change
  • Signs/symptoms of bleeding, LFTs, CBC, Hgb/Hct
• Dosing (general): 2 mcg/kg/min (actual body weight)
• Important notes:
  • Discontinue all heparin products including hep locks and coated catheters.  This includes all LMWH such as enoxaparin.
  • Causes false elevation of INR by cross-reacting with the INR assay

• radial head subluxation
• usually 1-3 years of age
• often after sudden longitudinal traction on extended arm with wrist in pronation
• tearing of annular ligament attachment to radial neck, with detatched portion trapped between subluxed raidal head and capitellum
• children refuse to use affected arm and hold in a flexed pronated position
• traditionally, reduce by supination of forearm with elbow in 90degrees of flexion
• newer reduction technique, hyperpronation with elbow flexion has better success rateand less pain

The mounting evidence on the use of 20% lipid emulsion or intrlipid has been growing for  any patient that is hemodynamically unstable due to a drug exposure. There is now a recent case report of a verapamil overdose patient that received intralipid and did well. They were able to measure verapamil levels before and after administration. They were able to remove the lipid from the serum to appropriately measure the level and found effective removal. This adds to the theory of the "lipid sink" where the lipid actually is binding/surrounding a lipophilic molecule effectively removing it from interaction.

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• Don't forget to give aspirin to patients presenting with acute ischemic stroke (AIS).

• Large trials such as the International Stroke Trial (IST)  and Chinese Acute Stroke Trial (CAST) have shown that starting 160 to 300 mg of aspirin within 48 hours of the presumed onset of ischemic stroke reduces the risk of early recurrent ischemic stroke, with no major increased risk of hemorrhagic conversion and with improved long-term outcome.

• Studies have also shown that high and low doses of aspirin (30 to 1200 mg per day) after AIS yield similar efficacy for preventing vascular events, but that higher doses are associated with a greater risk of gastrointestinal hemorrhage.

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Hepato-Renal Syndrome

• Hepato-renal syndrome (HRS) is the development of acute kidney injury (AKI) in patients with advanced cirrhosis.
• HRS is traditionally divided into two types based upon how quickly AKI develops:
  • Type I: a rapid decline in function in less than 2 weeks
  • Type II: a slow decline in function over weeks to months
• Type I is more likely to be seen in the ED and is often due to a precipitating event such as:
  • GI bleed
  • Spontaneous bacterial peritonitis (SBP)
  • Hypovolemia from aggressive diuresis
• In ED patients with advanced cirrhosis and new, or worsening, AKI think about HRS. 
• If suspected, look for precipitants (i.e. SBP), restore volume with IVFs, avoid nephrotoxins (IV contrast), and administer vasopressor therapy when indicated.

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Question

49 y.o. female on Trimethoprim/sulfamethoxazole presents with rash and oral mucus membrane lesions. Diagnosis?

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Paroxysmal supraventricular tachycardia (PSVT) is a common tachydysrhythmia encountered in ED practice. PSVT in itself has not been found to be an isolated manifestation of myocardial infarction or unstable angina (i.e. "isolated" = in the absence of other concerning symptoms, such as anginal-type pain, etc.).  Nevertheless, some physicians will routinely test cardiac troponin levels to evaluate for ACS in these patients. We should all remember, though, that tachydysrhythmias including PSVT are a potential cause of elevated troponin levels in the absence of coronary disease, and these elevations do NOT correlate with adverse outcomes unless other concerning symptoms/signs are present as well.

A recent study¹ corroborated this point: 11 out of 38 patients with PSVT had a positive troponin level. Only 2 of the 11 ruled in for ACS, and all of the patients were well at 30 days. Both patients presented with hypotension (SBP in the 70s) and also had other concerning symptoms, such as chest pain (both), dizziness (both), and dyspnea (one).

The takeaway point is simple: if you routinely send troponin levels on your patients for PSVT in the absence of other concerning symptoms/signs, you'll find yourself chasing a lot of false-positive levels.

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Pes Anserine Bursitis is an inflammatory condition of the medial knee

Occurs at the bursa of the pes anserinus which overlies the attachment of the 1) Sartorius 2) gracilis and 3) semitendinosis tendons

Note the location is 2-3 inches below the knee joint on the medial side

http://kneespecialistsurgeon.com/images/uploaded/Pes%20anserinus%20bursitis%20image.jpg

http://eso-cdn.bestpractice.bmj.com/best-practice/images/bp/en-gb/575-27_default.jpg

Patients complain of pain (especially with stair climbing)

PE: Tenderness to palpation of the bursa with mild swelling

DDx: MCL tear, medial meniscus injury, medial (knee) compartment arthritis

Treatment: Cessation/modification of offending activities, Icing and ice massage, NSAIDs, hamstring stretching and physical therapy. Failure of the above should prompt referral for bursal steroid injection.

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• second most common vasculitis of childhood
• leading cause of acquired heart disease in children
• usually in children <5years old
• year-round with clusters in spring and winter
• highest incidence in children of asian decent
• clinical diagnosis requires fever for at least 5 days and a minimum of 4 of the following:

1. bilateral conjunctival injection without exudate
2. rash (often macular, polymorphous with no vesicles, most prominent in perineum followed by desquamation
3. changes in the skin of the lips and oral cavity (red pharynx, dry fissured lips, strawberry tongue)
4. changes in the extremities (edema, redness of hands and feet followed by desquamation)
5. cervical lymphadenopathy

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• Idiopathic Intracranial Hypertension (IIH), previously known as Pseudotumor Cerebri, should be considered as a possible etiology of recurrent, often daily, headaches, particularly in obese, female patients.

• The pain is typically throbbing, sometimes unilateral, and severe.  In addition to headache, these patients often present with transient visual abnormality (72%), pulsatile tinnitus (60%), photopsia (seeing lights, flashes, colors) (54%), retrobulbar pain (44%), diplopia (38%), and sustained visual abnormality (26%).

• The most commonly encountered physical examination findings are (1) papilledema - the greater, the higher the risk for vision loss, (2) visual field loss (always check!), and (3) sixth cranial nerve palsy - due to increased pressure on this long-coursing intracranial nerve.

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Cancer patients admitted to ICUs with AKI or who develop AKI during their ICU stay have increased risk of morbidity and mortality. AKI in cancer patients is typically multi-factorial:

Causes indirectly related to malignancy

• Septic, cardiogenic, or hypovolemic shock (most common)

• Nephrotoxins:

  • Aminoglycosides

  • Contrast-induced nephropathy

  • Chemotherapy 

• Hemolytic-Uremic Syndrome

Causes directly related to malignancy

• Tumor-lysis syndrome

• Disseminated Intravascular Coagulation

• Obstruction of urinary tract by malignancy

• Multiple Myeloma of the kidney

• Hypercalcemia

Because AKI increases the already elevated morbidity and mortality in these patients, prevention (e.g., using low-osmolar IV contrast, avoiding nephrotoxins), early identification (e.g., strict attention to urine output and renal function), and aggressive treatment (e.g., early initiation of renal replacement therapy) is essential.

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There are several complications of acute aortic dissection that emergency physicians must be familiar with.

These include:

• Cardiac tamponade (most common cause of death)
• Acute aortic regurgitation
• Stroke
• Free intrathoracic rupture
• Malperfusion syndrome (kidney, spinal cord, bowel, extremity, etc.)

*Key Pearl: If a patient with suspected or confirmed acute aortic dissection suddenly arrests consider cardiac tamponade.

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Patients with Non-STE-ACS should not be given any NSAIDs aside from aspirin...that includes COX-2 agents. These medications in patients with acute or recent NSTE-ACS have been associated with an increased risk of hypertension, reinfarction, heart failure, myocardial rupture, and death.

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Kocher Criteria for Septic Arthritis in Children:

Septic arthritis should be suspected in children that have a painful joint especially if they do not want to weight bear.  Orthopedics uses the Kocher Criteria to determine the probability of whether the joint is infected. 

Four elements make up the criteria:

• Erythrocyte Sedimentation Rate >40
• WBC > 12
• Non weight-bearing on the affected joint
• Fever.

If only one sign is present there is a 3% chance the child has a septic joint.

• 2/4 criteria = 40%
• 3/4 criteria = 93%
• 4/4 criteria = 99%

The true incidence of drug-induced seizure is very difficult to determine, however, a nice poison center study attempted to determine clinical factors associated with complications (potentially life-threatening) of drug-induced seizures. They found 3 predictors that demonstrated statistically significant associations:

1. Stimulant Exposure (i.e. cocaine, amphetamines etc)
2. Initial acidosis
3. Hyperglycemia (limitation they do not give incidence of DM)

They found a 60% complication rate in drug-induced seizures which is much higher than epileptic seizures. Makes sense since these patients are often sedated/altered or vomiting.

Stimulant Exposure is much more prominent in this population and has increased in mortality.

Interesting point with hyperglycemia, may be a novel marker for poor prognosis. Several studies have confirmed an association between hyperglycemia and increased neuronal injury and mortality in other settings like CVA and TBI.

Take home point - Drug-induced Seizure has a high complication rate in the ED. Watch for the 3 predictors as that may clue you in to the increased risk.

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• A persistent systolic blood pressure (BP) > 185 and/or a diastolic BP > 110, is a contraindication to thrombolytic therapy in acute ischemic stroke patients.

• In cases such as these, the following antihypertensive regimens may be used in order to attempt to proceed with administering thrombolytic therapy as soon as possible:

1. Nicardipine infusion 5 mg/hour; titrate up by 2.5 mg/h every 5 - 15 minutes as needed to a maximum of 15 mg/h; reduce to 3 mg/h once desired BP is reached,
2. Labetalol 10-20 mg IV over 1-2 minutes; may repeat once, OR
3. Other agents such as hydralazine or enalapril when appropriate.

• Note that these options are based on 2010 recommendations which no longer include the use of nitropaste, as was the case with the prior recommendations from 2007.

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AKI in the Critically Ill Cancer Patient

• Acute kidney injury (AKI) is common in the critically ill cancer patient and associated with worse outcomes.
• The incidence seems to be higher in patients with hematologic malignancies.
• Despite many different etiologies for AKI in cancer patients (tumor lysis syndrome, hypercalcemia, chemotherapeutic drugs, etc) the most common cause is sepsis, accounting for 58-65% of causes.
• Given the emphasis on early antibiotic administration in sepsis, be sure to double check the potential for nephrotoxicity of antibiotics for this patient population.  When possible, avoid nephrotoxic meds, such as aminoglycosides, that can worsen AKI.

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Question

13 y.o. with shoulder trauma (during basketball game). Arm held in adduction and exquisite scapular tenderness. Diagnosis?

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Proton pump inhibitors should be avoided in patients being treated with clopidogrel. PPIs appear to attenuate the effect of clopidogrel, and there's even some suggestion that the addition of PPIs to the medication regimen of patients taking clopidogrel may be associated with an increased risk of rehospitalization or death.

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Kienbock’s disease is a rare entity involving collapse of the lunate due to avascular necrosis and  vascular insufficiency.

Occurs most commonly in young adults aged 15 to 40 years.

Cause is unknown but believed to be due to remote trauma or repetitive microtrauma in at risk individuals.

Patients complain of wrist pain, stiffness and swelling

On exam, limited range of motion, decreased grip strength and passive dorsiflexion of the 3^rd digit produces pain.

Dx: plain film in the ED and with MRI as an outpatient.

Tx:  Wrist immobilization with splint and refer to orthopedics. Ultimate treatment is individualized and there is no clear consensus.

Lunate sclerosis seen on plain film

http://orthoinfo.aaos.org/figures/A00017F02.jpg

AVN of the lunate seen on MRI

http://www.assh.org/Public/HandConditions/PublishingImages/KeinbocksMRI_figure3.JPG

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