Shoulder Dislocation Reduction

Do you have a chronic dislocated that frequents your ED? Are you interested in teaching them a way to relocate their shoulder without looking like Mel Gibson from Lethal Weapon, https://youtu.be/Igrdi_lhhW4, then the newly described GONAIS method might be what you are looking for.

This technique has the patient grab the top of a chair with the hand on the affected side, and then slowly equating, effectively bringing the hand and arm above their head. Once in the full squat position the patient can step backwards which should reduce the shoulder. If not they can use the opposite hand to apply pressure to push the humerus backward and reduce the location.

The full article can be found at http://bit.ly/1iZ8a9z

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Is there a set of criteria similar to the Ottawa Ankle or Knee Rule that can be applied to the wrist in children?
The Amsterdam Pediatric Wrist Rules are as follows:
-Swelling of distal radius
-Visible deformity
-Painful palpation of the distal radius
-Painful palpation at the anatomical snuff box
-Painful supination
A positive answer to any of these would indicate the need for an xray.

The study referenced attempted to validate these criteria. This criteria is inclusive of the distal radius in addition to the wrist. The sensitivity and specificity were 95.9% and 37.3%, respectively in children 3 years through 18 years. This model would have resulted in a 22% absolute reduction in xrays. In a validation study, 7/170 fractures (4.1%, 95% CI: 1.7- 8.3%) would have been missed using the decision model. The fractures that were missed were all in boys ages 10-15 and were all buckle fractures and one non displaced radial fracture.

Bottom line: This rule can serve as a guide for when to obtain an xray in the setting of trauma, but it is not perfect.

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Monosodium glutamate

• Rapid onset 30 min and lasts about 1 hour
• May accompanied with headache & chest pain.
• No associated GI sx.
• History of eating Chinese fodd. AKA "Chinese restaurant syndrome"

Metabisulfites (Na sulfite, Na/K bisfulfite, Na/K metabisulfite, etc.)

• Food preservatives found in dried fruit, wine, molasses, sauerkraut, etc.
• Bronchospasm – asthma like, headache, mild hypotension can occur
• Most significant reaction in people with asthma/allergies
• History of trying to eat "healthy"

Tyramine reaction

• Mostly among patients taking MAO inhibitors
• Source of tyramine (food): fermented, pickled product, avocado, chocolate, etc.

Niacin

• Burning warm sensation to body
• Often used for sexual enhancement, elevated cholesterol and beating drug urine screens

Trichloroethylene

• Occupational exposure – AKA “Degreaser’s flush”
• Facial flushing, head pressure, lacrimation & blurred vision may occur
• Require several weeks of exposure prior to symptoms

Scrombroids

• Occurs after a “fish meal” (e.g. dark meat fish - tuna)
• Associated with GI symptoms (nausea, vomiting, diarrhea)
• Histamine related reaction due to poor refrigeration after catching fish.

Hydroxocobalamin

• Antidote for CN poisoning
• Skin become red after administration due to its color (red)

Which infectious disease listed as Class A agents occur naturally, though sporadically within the U.S?

• Anthrax- primarily in the West and Southwest (including Texas)
• Plague- western United States
• Tularemia- in all states except Hawaii, but most common south central US
• Botulism- throughout the U.S. Most common type reported is infant botulism
• Dengue- primarily Puerto Rico. Within the continental US, a small outbreak was reported from south Texas.

Small pox no longer occurs naturally and other viral hemorrhagic fevers occur in tropical settings.

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SIMV (Synchronized intermittent mandatory ventilation)

• A common mode of ventilation that all pratitioners should be familiar with
• It provides a minimum number of fully assisted breaths synchronized with patient respiratory effort
• Patient or time triggered
• Flow limited
• Volume cycled
• Any additional breaths are unassisted and determined by patient effort
• SIMV=AC when heavily sedated
• The idea is exercise the patients lungs but this can lead to increased work of breathing and fatigue, and prolong extubation when used

Question

35 year-old female presents to the Emergency Room with cough and chest tightness. She was discharged from the hospital yesterday for an asthma exacerbation that was secondary to pneumonia. What's the diagnosis?

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In the evaluation of ED patients, it may be important to understand the effect on pupil size from the ophthalmic medications they use. Here is a summary chart of common eye drops and their effect on pupil size.

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Serotonin Syndrome - What is It?

• Potentially life-threatening condition associated with increased serotonergic activity in the CNS.
• Selective serotonin reuptake inhibitors (SSRIs) are the most commonly implicated class of medications.  However, other medications can also be involved.
• It is a clinical diagnosis!
• Classic triad: mental status change, autonomic hyperactivity, and neuromuscular abnormalities
  • Mental status change - anxiety, agitation, restlessness, disorientation
  • Autonomic hyperactivity - diaphoresis, tachycardia, hypertension, hyperthermia, nausea, vomiting, diarrhea
  • Neuromuscular abnormalities - tremor, muscle rigidity, myoclonus, hyperreflexia, clonus, Babinski sign (abnormal plantar reflex)
• Hunter Criteria is the most accurate diagnostic rule:
  • Serotonergic agent + one of the following:
    • Spontaneous clonus
    • Inducible clonus + agitation or diaphoresis
    • Ocular clonus + agitation or diaphoresis
    • Tremor + hyperreflexia
    • Hypertonia + temperature above 38C + ocular clonus or inducible clonus
• Majority of cases present within 24 hours, most within 6 hours, of a change in dose or initiation of a medication.

** Stay tuned for part 2 on what causes serotonin syndrome **

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Hyperoxia in the Critically Ill

• Oxygen is liberally administered to many critically ill patients, thereby exposing them to supranormal arterial oxygen levels.
• Hyperoxia results in the formation of reactive oxygen species, which adversely affect the pulmonary, vascular, cnetral nervous, and immune systems.
• Though the optimal P_aO₂ remains unknown, recent evidence indicates that hyperoxia is associated with increased mortality in post-cardiac arrest, CVA, acute coronary syndrome, and traumatic brain injury patients.
• Take Home Point: Carefully titrate oxygen to the lowest tolerable level to meet the patient's needs.

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Question

68 year-old man presents with a new-onset seizure. What's the diagnosis and what's in your differential diagnosis?

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A new prospective, randomized, double-blind trial compared subdissociative ketamine to morphine for acute pain in the ED.

What they did

• 45 patients received IV ketamine 0.3 mg/kg (mean baseline pain score 8.6)
• 45 patients received IV morphine 0.1 mg/kg (mean baseline pain score 8.5)
• Source of pain was abdominal for ~70% in each group
• Exclusion criteria was pretty standard

What they found

• Pain score at 30 minutes: 4.1 for ketamine vs. 3.9 for morphine (p = 0.97)
• No difference in the incidence of rescue fentanyl analgesia at 30 or 60 minutes
• No serious adverse events occurred in either group
• Patients in the ketamine group reported increased minor adverse effects at 15 minutes post-drug administration

1. In an effort to reduce opioid use in the ED, low-dose ketamine may be a reasonable alternative to opioids for acute analgesia.
2. State nursing regulations govern who can administer IV ketamine in the ED.
3. What to prescribe on discharge? Lead author Dr. Motov recommends a "pain syndrome targeted" approach with "patient-specific opioid and non-opioid analgesics."

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Injuries are a leading cause of morbidity and mortality globally

• Approximately 5.8 million deaths annually
• 90% occur in lower and middle income countries

Injuries are the leading cause of preventable death in travelers

• Cause 18%–24% of deaths among U.S. travelers
• From 2011-2013, an estimated 2,466 US citizens traveling in foreign countries died from non-natural causes, such as injuries and violence
  • Excluded the wars in Iraq and Afghanistan
• Main causes for non-natural deaths among Americans are:
  • Motor vehicle crashes (n= 621, 25%)- the single largest cause
  • Homicide (n=555, 23%),
  • Suicide (n=392, 16%),
  • Drowning (n=309, 13%)

Bottom Line: Stay safe while travelling.  The same safety habits used in the US, such as wearing your seatbelt or not drinking and driving, are important patterns while traveling.

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Your ESLD patient is hypotensive with a tense abdomen, and he needs a paracentesis!

--ALWAYS use ultrasound to localize a fluid pocket [Fig 1]! Take the time to use color Doppler to look for underlying abdominal wall varices [Fig 2]. Cirrhotic patients frequently have abnormal abdominal wall vasculature [1-2].

--Hemorrhage from paracentesis is exceedingly rare, and reversal of mild coagulopathy probably isn't that important [3-4].

--In hypotensive patients, consider placement of a small pigtail catheter for slow, continuous drainage (e.g. 8.3F pericardiocentesis catheter) instead of large-volume paracentesis. Non-tunneled catheter infection risk goes up after 72h [5].

--Albumin replacement improves mortality and incidence of renal failure in patients with SBP or other infection [6-7].

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Attachments

• 1509011640_Figure_1_--_Ascites_pocket.jpg (78 Kb)
• 1509011640_Figure_2_--_Color_over_abd_wall_varices.jpg (89 Kb)

Question

Person presents following a fall on an outstretched hand and there is snuffbox tenderness. What's the diagnosis?

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Policeman's Heel:

When patient's present complaining of heel pain we often think immediately of plantar fascititis,and heel spurs. If they jumped and landed on the heel with are concerned for calcaneal fracture.  However, a policeman's heel can occur from repetitive bounding of the heel or from landing on it as in a fall or jump.

Policeman's heel has been descirbed as a plantar calcaneal bursitis, inflammation of the sack of fluid (bursa) under the heel bone, or a contusion of the heel bone due to flattening and displacement of the heel fat pad, which leaves a thinner protective layer allowing the bone to get bruised.

Regardless of cause this responds well to NSAIDs, limiting weight bearing, or taping the foot. If the repetitive activity is not reduced this can easily become a chronic cause of heel pain.  A short video showing how to tape the foot can be found at https://youtu.be/nQtkwfJrhXo

Making the wee patient pee – a non invasive urinary collection technique in the newborn

Obtaining a urinary sample in a neonate can be challenging and time consuming. The most commonly used non-invasive technique is urine collection using a sterile bag. This technique is limited by patient discomfort and contamination of the urinary sample. Catheterisation and needle aspiration are other options, but are more invasive.

A prospective feasibility and safety study enrolled 90 admitted infants aged under 30 days who needed a urine sample into the study [1]. They performed the following stimulation technique.

1.     Feed the baby through breast-feeding or an appropriate amount of formula for their age and weight.

2.     Wait twenty-five minutes. After twenty-five minutes clean the infant’s genitals thoroughly with warm water and soap. Dry with sterile gauze.

3.     Have an assistant hold a sterile urine container near the infant

4.     Hold the baby under their armpits with their legs dangling (if short handed, parents can do this)

5.     Gently tap the suprapubic area at a frequency of 100 taps or blows per minute for 30 seconds

6.     Massage the lumbar paravertebral zone lightly for 30 seconds

7.     Repeat both techniques until micturition starts. Collect midstream urine in the sterile container

In the study, success was defined as obtaining a midstream urinary sample within 5 minutes after initiation of the stimulation procedure. There was a 86% success rate (n=69/80). Mean time to sample collection was 57 seconds. There were no complications, but controlled crying occurred in 100% of infants.  The study was limited by the lack of a control group. Previous studies have described longer collection times with traditional non invasive techniques, up to over an hour [2].

Conclusion

Consider the above mentioned stimulation technique to obtain a urinary sample in the neonate.

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Status migrainosus is a migraine that lasts more than 72 hours, and can be rather challenging to control. A few tips to tackle this are:

1. Adequately hydrate all patients (IV fluids are usually required, especially with severe nausea/vomiting)

2. Establish realistic expectations for the patient. A patient with chronic daily headaches will not be pain-free in the ED.

3. Use IV nonopioid medications for pain control

1^st Line:

- Dopamine Antagonists: in increasing efficacy

- Metoclopramide

- Phenothiazines: prochlorperazine, promethazine and chlorpromazine

- Butyrophenones: droperidol and haloperidol

- NSAIDs: such as Ketorolac IV or IM

2^nd Line:

- Corticosteroids: Do not treat the migraine in the ED, but prevent headache recurrence within 72 hours.

- Magnesium Sulfate: Has shown mixed efficacy. More likely to have a sustained benefit in patient with serum magnesium level of 1.3mg/dL or less.

- Valrpoic Acid: Be careful of combining it with Topiramate.

- Vasoconstrictors: Triptans, ergotamine, dihydroergotamine. Effective, but use is limited by contraindications.

- Opioids: Last resort

The RV is a low-pressure chamber that doesn’t tolerate acute increases in pulmonary pressures (e.g., ARDS, pulmonary embolism, etc.); acute increases can lead to RV dysfunction / failure

Managing RV dysfunction requires a three-pronged approach:

• Optimize preload – give small fluid boluses (e.g., 250cc) but not too much, because too much can worsen RV function. Use ultrasound to determine volume status
• Optimize RV function – Consider starting inotropes (e.g., dobutamine) for better RV contractility and concurrently start pulmonary vasodilators (e.g., inhaled nitric oxide); also minimize hypoxemia and hypercarbia
• Prevent systemic hypotension – hypotension reduces coronary perfusion that leads to RV ischemia and dysfunction; use norepinephrine to keep blood pressure >65
• Bottom-line: Don't under-estimate the importance of the RV when resuscitating your patients 

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Question

You find this interesting view while scanning a patient. Which view is this and why should you care about it? 

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Sodium Supplementation and Exercise-Associated Hyponatremia (EAH) during Prolonged Exercise (ultramarathon running)

Weight loss of around 4% body weight (relative to pre race weight) can be anticipated to maintain euhydration in such a prolonged event

Those who become symptomatic with EAH have either gained weight or lost less that 3-4% body weight

Overhydration rather than inadequate supplemental sodium intake is a greater contributor to the development of EAH

There is a suggested link between EAH and rhabdomyolysis. The mechanism remains unknown and it is unclear which condition may augment the other. Further research is needed.

Take home: Avoid overhydration during prolonged exercise to prevent EAH.

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