Drug-induced hypoglycemia is an often severe and symptomatic. It is a potentially preventable cause of significant morbidity. In one large study, it accounted for 23% for hospital admissions due to adverse drug events and 4.4% of overall admissions. The majority of hypoglycemic events occur with insulin and sulfonylureas. However, multiple drugs can affect glucose homeostasis and have been cited to cause hypoglycemia in therapeutic dose alone or in combination with other medications or illness. Factors that predispose to low blood sugar include reduced food intake, age, hepatic and renal disease, and severe infection. Beware of the possibility of inducing hypoglycemia in patients taking the following:

• Ethanol
• Insulin
• Pentamidine
• Quinine
• Quinolones (Gatifloxin others rare)
• Sulfonylureas

Agents with lesser quality evidence as predisposing medications or illnesses were present:

• Ace Inhibitors (with diabetic agents)
• Propanolol ( less likely in other beta blockers)
• Trimethoprim/sulfamethoxazole (in renal compromise)
• Salicylates (high dose or intoxication)

Drugs induced hypoglycemia should always be considered in the differential diagnosis of every patient presenting with low blood glucose. Octreotide antagonizes pancreatic insulin secretion and should be considered for first-line therapy in the treatment of sulfonylurea-induced hypoglycemia particularly when glucose levels cannot be maintained by dextrose infusions. Octreotide is administered 50 mcg subcutaneously (1-10 mcg in children) every 12 hours.

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Recently, there have been several news reports regarding the emergence of synthetic opioids in the U.S. and Canada. There are multiple synthetic opioids that have been identified as potential agents of abuse including W-18, U-47700, fentanyl derivatives, AH-7921 and MT-45. These compounds share a similar story with synthetic cannabinoid where they were synthesized for research purpose or by pharmaceutical companies but were not marketed. They are often sold as “research chemicals” over the internet.

In July 2016, three case reports have been published regarding several cases of U-47700 intoxication in San Diego, CA and Dallas, TX.

• Dallas, TX: A couple in their 20’s purchased U-47700 on the internet believing it to be “synthetic cocaine.” They both suffered CNS and respiratory depression after insufflation. Naloxone was not administered in both cases. The man was intubated while the woman was awake at time of presentation to the ED. U-47700 exposure was confirmed by liquid chromatography/tandem mass spectrometry.

• San Diego, CA: a 22 year old man with history of heroin abuse was found unresponsive and apneic (4 breaths per minute and pulse oximetry of 60%). He received naloxone 2 mg IV which completely reversed his CNS and respiratory depression. He admitted to purchasing U-47700 on the internet and its use prior to being found unresponsive. U-47700 exposure was confirmed using liquid chromatography/mass spectrometry.

• Central CA: 41 year old woman presented with CNS depression and pinpoint pupils after ingesting 3 tablets of “Norco” purchased from the street.  Her intoxication was completely reversed with naloxone 0.4 mg IV and discharged after 4 hour observation. Fentanyl and U-47700 was detected in serum blood test.

It is unknown if currently available heroin is cut with above mentioned synthetic opioids. Like other opioid receptor agonists, administration of naloxone will likely reverse the opioid toxidrome. But clinical experience in reversing synthetic opioids intoxication with naloxone is limited.  

Bottom line:

Irrespective of whether an ED patient is exposed to synthetic opioids or "traditional" opioids of abuse (prescription opioid pain medication or heroin), the management of opioid intoxication management remains unchanged for respiratory depression. 

1. Airway management: bag-valve assisted ventilation if needed
2. Naloxone administration (initial dose: 0.04 to 0.4 mg IV) with titration as needed. 

• naloxone's clinical duration of effect ranges from 30 to 90 minutes.

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An Arbovirus is a virus transmitted primarily by an arthropod

• Comes from ARthropod-BOrne virus
• Arthropods include: mosquitos, ticks, sandflies
• Can have rare person-to-person transmission
  • Blood borne
    • Transfusion, sharing needles
  • Organ transplantation
  • Breast feeding
  • Intrauterine
  • Sexual transmission

There are a number of major arbovirus families:

• Family Bunyaviridae
  • Rift Valley, Crimean–Congo hemorrhagic
• Family Flaviviridae
  • Dengue, West Nile, Zika, Yellow Fever
• Family Reoviridae
  • Equine encephalosis
• Family Togaviridae
  • Chikungunya, Western equine encephalitis

The main viral family that causes substantial human disease is the Flaviviridae family.

• Protection against mosquito bites is the best way to minimize risk for Flaviviridae infections if you are traveling in an area with these diseases.

Despite a lack of prospective data, end-tidal CO2 (ETCO2) is often proposed as a viable replacement for the traditional pulse check to identify return of spontaneous circulation (ROSC) in patients presenting to the Emergency Department in Cardiac Arrest. A recent study by Tat et al examined this very question. The authors prospectively enrolled 178 patients suffering out-of-hospital cardiac arrest (OHCA) and examined the accuracy of a rise in ETCO2 at predicting ROSC. The authors examined both a rise of 10 and 20 mm Hg in ETCO2. Of the 178 patients included in this cohort, 60 (34%) experienced ROSC. The sensitivity and specificity of ETCO2 to predict ROSC at a threshold of 10 mm Hg was 33% and 97% respectively. At a threshold of 20 mm Hg ETCO2 performed no better with a sensitivity and specificity of 20% and 99% respectively.

What this data suggests is while a rise of ETCO2 of greater than 10 is highly suggestive of ROSC, the contrary cannot be said. The absence of a spike in ETCO2 does not rule out ROSC, as the large majority of patients experiencing ROSC in this cohort did so without demonstrating a significant rise in ETCO2. This evidence suggests that ETCO2 is a poor surrogate for a pulse check.

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The pediatric epiglottis is more "U" shaped, often overlies the glottic opening, and is "less in line with the trachea."¹ Because of this, it has traditionally been taught that a Miller blade is the ideal laryngoscope.

Varghese et al compared the efficacy of the Macintosh blade and the Miller blade when placed in the vallecula of children between the ages of 1 and 24 months. The blades provided similar views and suffered similar failure rates. When the opposite blade was used as a backup, it had a similar success rate as the opposing blade.² Passi et al also compared these two blades, this time placing the Miller blade over the epiglottis. Again, similar views were achieved.³

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Predicting Fluid Responsiveness with ETCO2

• It is well known that almost 50% of critically ill patients do not respond to fluid resuscitaiton. For those that do not respond, indiscriminate fluid administration may be harmful.
• There is increasing emphasis on the use of dynamic markers of fluid responsiveness, namely passive leg raise (PLR), pulse pressure variation, respirophasic changes in the IVC, and many others.
• ETCO2 can also be used to assess fluid responsiveness in mechanically ventilated patients with no spontaneous respiratory effort.
• An increase in ETCO2 of at least 5% with a PLR has been shown to outperform arterial pulse pressure as a measure of fluid responsiveness.

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30yo male weight lifter who 10 days ago had a painful left shoulder injury after bench press. The next morning his left anterior chest wall and left upper arm were bruised and swollen. He went to see his PCP who diagnosed him with a muscle strain. 8 days later the bruising and swelling have resolved but he still cant move his shoulder and comes to the ED.

http://321gomd.com/wp-content/uploads/2015/01/pec-major-tears.jpg

The pec major attaches to the humerus and originates from the sternum and clavicle

Injury is usually due to tendon rupture off the humerus but can also occur at the muscle tendon junction or within the muscle belly itself.

Injury is becoming increasingly common due to the popularity in power lifting sports.

Mechanism: excessive tension on a maximally eccentrically contracted muscle.

Patients will complain of pain and weakness of the shoulder.

PE: Swelling and bruising to anterior medial arm. Palpable defect and deformity or anterior axially fold (may be hidden by swelling).

Weakness and pain with adduction and internal rotation and forward flexion

Chronic presentations can be challenging to diagnose. Consider ultrasound

Non operative treatment may be indicated for partial tears (sling, ice, NSAIDs)

Operative repair of tendon avulsions is very successful. Patients age, occupation/activity level and location of injury and condition of tear are considered.

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• Just the Facts:

  • 112.5-million blood donations globally and half of these come from High-income countries

  • High-income countries more often use blood for supportive care during surgery, in traumas or therapy for malignancies

  • Low and middle-income countries more often use blood to manage pregnancy-related complications or in severe childhood anemia

  • General availability of blood is based on the donation rate

    • High-income countries have 33.1 donations/1000 people

    • Middle-income countries have 11.7 donations/1000 people

    • Low-income countries have 4.6 donations/1000 people

  • 70 countries reported collecting fewer than 10 donations per 1000 people and half of these countries were in the African region

  • Disease prevalence in the region is reflected in the transmission rate of transfusion-transmissible infections (TTI)

Table 1. Prevalence of TTIs in blood donations (Median, Interquartile range (IQR)), by income groups

Submitted by: Dr. Laura Diegelmann

Non-Musculoskeletal Causes of Neck Pain

Neck pain is a common complaint of people presenting to the ED. Most of the cases will be musculoskeleteal in origin and will respond to conservative therapy with NSAIDs or acetominophen. However, other non-musculoskeletal causes of pain could be lurky behind this benign complaint.

Don't forget to consider:

1. Early mengingitis (84% of patients with meningitis will complain of neck stiffness)
2. Myocardial infarction/angina. Women are known to have atypical symptoms and might just have dull pain in their neck. Be sure to ask about whether exertion increases the pain.
3. Epidural Abscess- fever and neuro symptoms are often missing early on. Make sure to ask about risk factors for spinal epidural abscess.
4. Vertebral Artery Discection - most common identifiable cause of stroke in your people.  <50% are associated with trauma and <8% of patients have connective tissue disorder. Patients are at increased risk if they have had
   1. Cervical trauma (remember seen in < 50% of cases)
   2. Recent infection
   3. Hypertension
   4. h/o migraines

Although it is summer, preparations are being made for the 2016-2017 influenza season. The Center for Disease Control (CDC) no longer recommends the live attenuated influenza vaccine (LAIV4). The American Academy of Pediatrics has supported this statement.

The LAIV4 (the only intranasal vaccine available) was offered to patients over the age of 2 years without respiratory problems. Observational studies during the 2013-2015 seasons have shown that the LAIV4 has an adjusted vaccine efficacy of 3% compared to 63% for the inactivated vaccine (intramuscular). Children who received the intranasal vaccine were almost 4 times more likely to get the flu compared to children who received the injection.

Bottom line: Only the intramuscular shot is recommended for this upcoming season. This is causing many primary care practices to scramble to obtain enough vaccine.

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• Endovascular intervention for acute ischemic stroke from ICA or proximal MCA occlusion is a Level IA recommendation¹.
• Identification of patients who may benefit from endovascular intervention begins in the prehospital setting.
• Several prehospital stroke scales exist, but have not been validated using arterial imaging to determine the presence of LVOS.
• The Field Assessment Stroke Triage for Emergency Destination (FAST-ED) scale (see Table 1) was designed based on items of the NIH Stroke Scale (NIHSS) with higher predictive value for LVOS.

• The FAST-ED scale has comparable accuracy to predict LVOS to the NIHSS, and higher accuracy compared to the Rapid Arterial Occlusion Evaluation (RACE) and the Cincinnati Prehospital Stroke Severity (CPSS) scale
• The FAST-ED scale also provides 3 distinct groups for the likelihood of LVOS:
  • Score 0 or 1: <15%
  • Score 2 or 3: 30%
  • Score >= 4: >60%

Bottom Line: Additional assessment of gaze deviation, aphasia and neglect, as included in the FAST-ED scale, increases the accuracy of predicting LVOS.  

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LVADs and RV Failure

• Acute RV failure can be seen in up to 10% of patients after LVAD implantation.
• The treatment of RV failure in the LVAD patient consists of the following:
  • Fluids: avoid aggressive fluid administration, as this can displace the septum and impair LVAD function
  • Inotropes: consider early initiation of dobutamine, milrinone, or epinephrine to augment RV function
  • Vasopressors: target a MAP higher than 60 to 70 mmHg to maintain RV perfusion pressure
• If intubated, avoid hypoxia, hypercarbia, high PEEP, and high ventilator pressures.  These can increase pulmonary vascular resistance and further worsen RV function.

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Sesamoid Injuries

Unlike other bones in the human body that are connected to each other at joints, sesamoid bones are only connected via tendons (or are imbedded in muscle).

The largest sesamoid bone is the patella.

2 small sesamoid bones lie on the plantar foot near the great toe

Sesamoid bones can fracture and the surrounding tendons can become inflamed (sesamoiditis)

Traumatic injury is usually due to hyperextension and axial loading

Sx: Pain located under the great toe on the ball of the foot (Gradual with sesamoiditis and acutely with a fracture).

There may be associated swelling and bruising. Pain with palpation, flexion and extension.

The medial/tibial sesamoid is larger, has great weight bearing status and is more commonly injured that its lateral counterpart.

In many people (10 - 25%) the medial sesamoid of the foot has two parts (bipartite). This finding is bilateral in 25% of people.

This may confuse some providers as it may appear to be a fracture

Look for a smooth contour to the bones and clinically correlate (bruising, soft tissue swelling, etc.) if it is an incidental finding.

Other radiographic clues include

1) The fractured sesamoid is usually slightly larger than the lateral sesamoid while the bipartite sesamoid has a much larger medial sesamoid than lateral sesamoid

2) The fractured sesamoid shows a sharp, radiolucent, uncorticated line between the two fragments while the bipartite sesamoid has two corticated components

3) The fractured sesamoid fragments often fit together like pieces of a puzzle while the bipartite sesamoid has two components that do not fit together snugly

4) Other means to differentiate the two involve MRI and bone scanning

Treatment involves a stiff-soled shoe or applying a cushioning pad or J-shaped pad around the area to relieve pressure.

It may take months for the pain to subside.

http://www.apfmj-archive.com/afm5_3/afm50.htm#F1

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There are many definitions for a disaster.  Per the International Federation of Red Cross and Red Crescent Societies (IFRC), they define a disaster as:“…a sudden, calamitous event that seriously disrupts the functioning of a community or society and causes human, material, and economic or environmental losses that exceed the community’s or society’s ability to cope using its own resources. Though often caused by nature, disasters can have human origins.”

However, in the heat of the moment, a shorter definition is easier to remember. The IFRC also define a disaster as:

• DISASTER = (VULNERABILITY+ HAZARD ) / CAPACITY

A shorter, more practical definition is:

• DISASTER = Needs > Resources

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Fluoroquinolone antibiotics are used to treat a wide range of infections and as prophylaxis against infection in certain immune compromised patients. In 2008 the FDA issued a boxed warning for tendonitis and tendon rupture for the fluoroquinolone antibiotic class, and in May 2016 a statement recommending the use of alternate therapies for uncomplicated UTIs and upper respiratory infections was issued. The mechanism by which fluoroquinolones causes tendon injury has not been elucidated, but may be related to oxidative stress caused by the overproduction of reactive oxygen species in tenocytes.

Adverse event reporting to the FDA is performed voluntarily by healthcare professionals and consumers through MedWatch. An analysis of tendon rupture events associated with fluoroquinolone use reported to the FDA’s Adverse Event Reporting System (FAERS) database was recently published.

What they found:

• 2495 reported cases of tendon rupture associated with fluoroquinolones
• Most cases involved levofloxacin (n=1555), ciprofloxacin (n=606), or moxifloxacin (n=230).
• Concomitant corticosteroids were administered in 21.2% of cases.
• The mean age was approximately 60 +/- 5 years.
• The ratio of men:women was 1.16:1.
• Renal function was not reported in this study.

Application to clinical practice:

• There is a risk of tendonitis/tendon rupture with administration of fluoroquinolone antibiotics.
• Risk factors for fluoroquinolone-associated tendinopathies may include advanced age, impaired renal function, and use of concomitant corticosteroids.
• Alternatives to fluoroquinolone antibiotics should be considered for patients with tendinopathy risk factors.
• When indicated, fluoroquinolones should be used at the lowest effective dose for the shortest possible time period to minimize exposure.

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Plain films are commonly used to screen children for pelvic fractures or dislocations following blunt torso trauma

The sensitivity of this common screening practice is unknown

A recent study looked at this question.

Of 451 patients with pelvic fractures or dislocations, 382 had AP radiographs. Injury was correctly identified in 297 patients (sensitivity 78%).

The sensitivity was greater in the sicker subgroups :92% for those requiring operative intervention and 82% for those with hypotension

Plain AP pelvic radiographs should have a limited role in the sole evaluation of children with blunt torso trauma.

They should be incorporated in the assessment of hemodynamically unstable children and those in whom the clinician is not planning on otherwise obtaining an abdominal/pelvis CT.

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Laundry detergent pods were introduced in 2012 to make washing clothes more "convenient." Since then, pediatric exposures to laundry detergent pods have increased as the use of these detergent pods have become more common in homes. Like other household chemical exposure, small, colorful candy like appearances of laundry detergent pods can attract the attention of < 3 years old children resulting in unintentional exposure due to curiosity or taste.

Most frequent clinical effects (2013 - 2014 national poison center data) from exposure to detergents in general (laundry detergent pods and nonpods & dishwasher detergent):

• GI: nausea & vomiting: 29.1%
• Cough/choking: 8.3%
• Ocular irritation/pain: 5.6%
• Red eye/conjunctivitis: 3.4%
• Drowsiness/lethargy: 2.8%

Laundry detergent pod vs. nonpods:

• Higher referral to health care facility: 17.4% vs. 4.7%
• Higher odds of experiencing > 1 clinical effects (OR: 3.9; 95% CI: 3.7 4.1)
• Higher odds of hospital admission (OR: 4.8; 95% CI: 4.0 5.8)
• Higher odd of intubation (OR: 6.9; 95% CI: 3.5 13.6)

Laundry detergent pods (only) also resulted in following:

• Coma: 17 cases
• Respiratory arrest: 6 cases
• Pulmonary edema: 4 cases
• Cardiac arrest: 2 cases

Cases of caustic exposure-like injuries have also been reported (corneal abrasion and esophageal injury)

Bottom line:

Pediatric laundry detergent (nonpods) exposures usually have self-limited symptoms. However, laundry detergent pod exposure can cause more serious clinical effects that may require hospitalization.

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Multiple sclerosis (MS) relapses are defined as new or worsening neurologic deficits lasting 24 hours or more in the absence of fever or infection. Symptoms may be visual, motor, sensory, balance or cognitive. It is a clinical diagnosis, but the presence of a new gadolinium-enhancing lesion on MRI can be used as a radiologic marker of an MS relapse. However, it is unclear whether asymptomatic lesions should be treated, making it prudent to rely on the clinical evaluation rather than the MRI for diagnosis.

Moderate to severe relapses should be treated within 1 week of onset. The mainstay of treatment for relapses is IV methylprednisolone, usually dosed at 500mg to 1g per day for 3-7 days.

Similar symptoms occurring in the presence of fever, heat exposure, stress or infection (such as urinary or upper respiratory tract infections) are "pseudoexacerbations", and should not be treated as an MS relapse.

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