Drug-induced hypoglycemia is an important cause of hypoglycemia which should be considered in any patient presenting with altered mental status. In one study, drug-induced hypoglycemia represented 23% of all hospital admissions attributed to adverse drug events. Risk factors for developing hypoglycemia include older age, renal or hepatic insufficiency, concurrent use of insulin or sulfonylureas, infection, ethanol use, or severe comorbidities. The most commonly cited drugs associated with hypoglycemia include:
*In Glipizide users, there was 2-3 fold higher odds of hypoglycemia with concurrent use of sulfamethoxale-trimethoprim, fluconazole, and levofloxacin compared with patients using Cephalexin.
**Tramadol potentially induces hypoglycemia by effects on hepatic gluconeogenesis and increasing insulin release and peripheral utlizilation. Was seen in elderly at initiation of therapy within first 30 days.
BOTTOM LINE:
Take care in prescribing drugs known to increase risk of hypoglycemia in elderly patients, with comorbidities, or those already taking medications associated with hypoglycemia.
Bottom Line: Consider using capillary refill as an alternate (or complimentary) endpoint to lactate clearance when resuscitating your septic shock patients.
The TACO method (tarp assisted cooling with oscillation)
Cold water immersion (CWI) remains the standard for cooling in exercise induced hyperthermia
A low cost alternative is modified cold water immersion.
Sometimes, monetary reasons and location venue prevent the feasibility of CWI
Benefits: fast, cheap, portable
Portable – Allows for on site location at area of collapse
Cheap: Equipment required – 3 providers, 1 tarp, 20 gallons of water and 10 gallons of ice
Fast: Average time to set up – 3.4 minutes
The TACO method – fast effective reduction in core temperatures
May be up to 75% as effective as CWI
https://www.youtube.com/watch?v=RxjP0-_RIdc
Management of Coagulopathy in Acute Liver Failure
Continuous home infusion therapies of medications such as insulin, milrinone, dobutamine, and pulmonary hypertension medication such as treprostinil are becoming more common. As a result, you may see these patients present to the emergency room and need to know the basics for checking the pump.
These questions are very important to determine if you will need to order a replacement infusion bag and run it on a hospital infusion pump, or if the patient can safely remain on their pump during the initial medical evaluation.
Guanfacine is a presynaptic alpha-2 adrenergic receptor agonist (similar to clonidine) that is FDA approved to treat ADHD in pediatric patients 6 years of age and older. A recently published study characterized the pediatric exposure to guanfacine between 2000 and 2016.
Most frequently reported clinical effect (n=10927)
Severe clinical effects (n=10927)
Duration of clinical effect
Conclusion
Many, if not nearly all, of our intubated patients in the ED have altered mental status, a potential to clinically worsen, or a requirement for medications that would alter their respiratory status (e.g. propofol, opioids, paralytics). It is imperative to place these patients on appropriate ventilator modes to avoid apnea when their respiratory status changes.
Gallstones account for 35-40% of cases of pancreatitis and the risk increases with diminishing stone size. Bile reflux into the pancreatic duct can form stones there, beyond where they can be visualized by ultrasound. Biliary colic may precede the pancreatitis, but not necessarily. The pain typically reaches maximum intensity quickly but can remain for days.
Alanine aminotransferase (ALT) > 3x normal is highly suggestive of biliary pancreatitis.
Abdominal ultrasound is not sensitive to common bile duct stones but may find dilation.
In the absence of cholangitis, endoscopic ultrasound or MRCP are sensitive tests and permit intervention. Patients who recover are much more likely to develop cholangitis, therefore cholecystectomy is indicated in patients after they recover from gallstone pancreatitis.
Bottom Line: a patient presenting with days of abdominal pain but an absence of gallstones or cholangitis may still suffer from gallstone pancreatitis which requires further intervention, including cholecystectomy.
Measles outbreaks have been reported all over the globe, with the incidence increasing due to low immunization rates. Italy experienced 5000 cases in 2017. This study was a retrospective multicenter observational study of children less than 18 years hospitalized for clinically and laboratory confirmed measles over a year and a half period from 2016-2017.
There were 263 cases of measles that required hospitalization during this time and 82% developed a complication with 7% having a severe clinical outcome defined by a permanent organ damage need for ICU care or death. A CRP value of greater than 2 mg/dL was associated with a 2-4 fold increased risk of developing complications. 23% developed pneumonia and 9.6% developed respiratory failure. Hematologic involvement was seen in 48% of patients. 1.2% of hospitalized patients died.
Bottom line: Consider CRP, lipase and CBC at a minimum in your patients with suspected measles who require hospitalization.
Single use laundry pods are readily available in many homes. Due to their bright colors, they have been mistaken for edible products (e.g. candy) by children.
A recent study reviewed 4652 laundry pod exposures from United Kingdom.
95.4% involved children aged < 5 years via oral route (89.7%).
Common symptoms in moderate/severe symptom groups, including fatality (n=127)
Conclusion
Mechanical Ventilation in the Obese Critically Ill
Most (65%) scans were performed at nonacademic adult centers
Over 630,000 children visit the ED every year with a diagnosis of concussion
Predictors of persistent post-concussive symptoms (PPCS):
Appromixately 1/3 of pediatric patients will have PPCS lasting over 2 weeks
Likelihood of PPCS increases to >50% in those with risk factors identified in the ED
Every state has a youth concussion law. The basic tenants are a) immediate removal from play b) written clearance from health professional to return to play c) education for athlete, parents, coaches.
Bottom Line: Use of IO allows more rapid administration of 23.4% NaCl with no immediate serious complications.
Background: Previous systematic reviews1,2,3 have indicated that the absence of cardiac activity on point-of-care ultrasound (POCUS) during cardiac arrest confers a low likelihood of return of spontaneous circulation (ROSC), but included heterogenous populations (both traumatic and atraumatic cardiac arrest, shockable and nonshockable rhythms).
The SHoC investigators4 are the first to publish their review of nontraumatic cardiac arrests with nonshockable rhythms, evaluating POCUS as predictor of ROSC, survival to admission (SHA), and survival to discharge (SHD) in cardiac arrests occurring out-of-hospital or in the ED.
Bottom Line: In nontraumatic cardiac arrest with non-shockable rhythms, the absence of cardiac activity on POCUS may not, on its own, be as strong an indicator of poor outcome as previously thought.
Elderly patients (mean age of 84 years) living in the community who are seen and discharged from the Emergency Department due to illness or injury are at increased risk for further disability and functional decline for at least six months after their visit. This is associated with increased mortality, cost and need for long term care in previously self-functioning individuals. * When appropriate to discharge from the ED, we should consider discharge planning that includes coordination with care management services to be sure these individuals have adequate home support systems in place and access to close outpatient follow-up.
*It should be noted that the risk is even greater after inpatient hospitalization.
Identifying serotonin syndrome in the emergency department can be difficult without an accurate patient history. Furthermore, the physical symptoms may look similar to many other disorders such as neuroleptic malignant syndrome and anticholinergic toxicity. If you remember the acronym SHIVERS, you can easily recognize the signs and symptoms of serotonin syndrome.
Shivering: Neuromuscular symptom that is unique to serotonin syndrome
Hyperreflexia and Myoclonus: Seen in mild to moderate cases. Most prominent in the lower extremities. This can help differentiate from neuroleptic malignant syndrome which would present with lead-pipe rigidity.
Increased Temperature: Not always present, but usually observed in more severe cases
Vital Sign Abnormalities: Tachycardia, tachypnea, and labile blood pressure
Encephalopathy: Mental status changes such as agitation, delirium, and confusion
Restlessness: Common due to excess serotonin activity
Sweating: Autonomic response to excess serotonin. This symptom can help differentiate from anticholinergic toxicity in which the patients would present with increased temperature but dry to the touch
Once serotonin syndrome is identified, it is important to discontinue all serotonergic agents, provide supportive care with fluids, and sedate with benzodiazepines. Sedation with benzodiazepines helps to decrease myoclonic jerks which also helps with temperature control. If patients are hyperthermic, they will require intensive cooling. Cyproheptadine, a potent antihistamine and serotonin antagonist, should also be administered. The initial dose of cyproheptadine in serotonin syndrome is 12mg which can be followed by 2 mg every 2 hours as needed for symptom control.
Intravenous lipid emulsion (ILE) is use as a therapy of last resort in refractory cardiovascular shock from toxicity of select agents (e.g. calcium channel blockers, beta blockers and select Na-channel blocking agents). There are number of case reports/series that showed positive cardiovascular/hemodynamic response after ILE, which are prone to publication bias. Results from limited number of human trials have shown mixed results.
A study reviewed fatal cases of poisoning that received ILE from the National Poison Data System to characterize the clinical response of ILE therapy.
Results
N=459 cases from 2010 to 2015.
Most common substance involved
|
| N (%) | Number with ROSC (%) |
| Ca-channel blockers | 183 (40) | 8 (4.4) |
| Beta blockers | 102 (22) | 5 (4.9) |
| Bupropion* | 53 (12) | 5 (9.4) |
| TCAs* | 48 (10) | 2 (4.2) |
| Citalopram/escitalopram | 36 (8) | 0 |
| Quetiapine | 26 (6) | 1 (3.8) |
| Flecainide | 21 (5) | 5 (23.8) |
| Local anesthetics – parenteral* | 8 (2) | 1 (12.5) |
*Use of ILE supported by Lipid work group
Response rate
Possible adverse reactions (n)
Conclusion
The Lung Transplant Patient in Your ED