Archive | April, 2014

caffeine content: quick reference

29 Apr

Need a quick reference for the usual caffeine content of that new energy drink or wild-sounding pill that your patient has been taking (possibly to excess)?  The internet will provide:

 

Death By Caffeine:

check out the website, which will tell you how much of a particular drug/food it will take to kill you, based on your weight.  Fun.

For some references on caffeine content, check out the top tabs, which can lead you by category (coffee brands, energy drinks, foods, etc) to your desired target.

For example:

  • 12 oz Diet Pepsi: 35 mg caffeine
  • 8.5 oz Red Bull : 80 mg
  • 20 oz Tim Hortons coffee: 200mg
  • 2 oz 5-hr Energy: 200mg
  • Excedrin: 65mg
  • Hershey Kisses: 1mg (per piece)

While away the hours.  Learn something new, like the fact that Stay Puft Caffeinated Marshmallows exist (100mg per mallow).

 

References: caffeineinformer.com; picture

 

 

 

Guillain-Barre Syndrome (quick hits)

28 Apr

GBS:
-Primarily an acute inflammatory demyelinating polyneuropathy (AIDP)
-Often associated with prodromal infectious organisms:
            -Campylobacter jejuni (patients with diarrhea history)
            -CMV
            -EBV
            -Mycoplasma pneumonia

Cause:
-It is believed that macrophages attack antigens on the myelin sheath that are extremely similar to antigen on certain organisms
 

Symptoms:
Progressive, symmetrical distal weakness usually worse in the lower extremities (ASCENDING PARALYSIS)
-Associated with diminished DTRs
-Can affect all four extremities in up to 40% of cases
-Ocular muscles are usually spared in this disease 
 
Prognosis:
-Nearly one third require ventilator assistance during their course
-Peak disease severity is usually a weak after onset
 

Diagnosis:
-MRI imaging showing selective enhancement of the anterior spinal nerve roots
CSF fluid showing a very high protein with only a mild pleocytosis
-Electrophysiologic testing
 
Management:
Respiratory Assessment:
-FVC measurement is essential to determine the need for intubation/impending respiratory failure
-FVC less than 20ml/kg is associated with pending respiratory failure
-NIF less than 30cm H20 are also more likely to require intubation
 
Therapy
IVIG or plasma exchange are treatment of choices
 
Blood Pressure
-It is advised not to treat hypertension in GBS as the hypertensive stage is often followed by the hypotensive stage
 

Submitted by Joey Grover.
 References: Rosen’s Emergency Medicine: 7th Edition; picture

Hemolytic Uremic Syndrome

25 Apr

HUS:

-One of the most common causes for acute renal failure in children

-Mean age of presentation is between 3-5 years of age

 

Associated infections:

E. Coli 0157:H7 is the most common

-Shigella, S. pneumonia, and certain drugs are also associated with causing HUS

 

Concept of the Disease

-Fibrin strands form along blood vessels causing microangiopathic hemolytic anemia

-Renal dysfunction occurs directly from injury to the renal vasculature, as well as from platelet/complement deposit in the glomerular lumen.

 

Symptoms:

-Prodromic gastroenteritis:  Abdominal pain, bloody diarrhea

-Later effects:  Thrombocytopenia, microangiopathic hemolytic anemia, renal failure

 

Prognosis:

-Up to 25% of patients had long term renal injury

-Up to 12% of patients develop end stage renal disease or even death

-Recurrences are a possibility with a high mortality (up to 30%)

 

Treatment:

Gentle fluid resuscitation and supportive care

-Treatment of hyperkalemia when present

Transfusions as needed (platelet transfusions are reserved only in cases of bleeding)

-Antibiotics are not recommended for the gastroenteritis as they have been associated with increased release of verotoxin possibly increasing the risk for HUS

Plasmapharesis can be considered in severe cases

 

Submitted by Joey Grover. 

 

References: Rosen’s Emergency Medicine:  7th Edition.  picture

Epiglottitis (quick hits)

24 Apr

General:

-Also can be referred to as supraglottitis

Haemophilus influenza type b (cause approximately 25% of cases even now after vaccination), Staphylococcus and Streptococcus species are the most common causes

 

Features:

-Classic 3 D’s= Drooling, dysphagia, and distress

-Commonly describe worsening dysphagia, dysnpea,

-Fever, tachycardia, and cervical lymphadenopathy also presently common

-Insiratory stridor

-Patients often are sitting in the sniffing position to provide easier breathing

 

Diagnosis:

Xrays can be obtained which show “thumb sign”if you are really concerned about epiglottis and the patient is unstable, do any necessary imaging at the bedside

-Transnasal fiberoptic laryngoscopy is the imaging test of choice

-CT is not needed and should be avoided in any patient who develops worsening symptoms with laying down

 

Treatment:

-Supplemental humidified oxygen

-ENT consultation

-IV antibiotics (Ceftriaxone is first line drug)

-IV steroids

-ENT consultation

 

NOTE:  If intubation is needed, try performing awake fiberoptic intubation in the OR with tracheostomy equipment available if needed

 

Submitted by Joey Grover. 

 

References: Image: http://www.nejm.org/na101/home/literatum/publisher/mms/journals/content/nejm/2011/nejm_2011.365.issue-5/nejmicm1009990/production/images/large/nejmicm1009990_f1.jpegTintinalli’s Emergency Medicine 7th Edition

obstacle race injuries

22 Apr

Interesting article in the March Annals, cases series of a few folks after a Tough Mudder in a Pennsylvania ED:

some highlights from the interesting unique cases:

18 yo M with chest discomfort after electrical shocks in the last obstacle; troponins rose to 23 by the 3rd TnI; diagnosed with myocarditis 2/2 electrical shock

a few syncope/seizure types, with diagnoses ranging from possible pericarditis, electrolyte imbalance (Na+ 127), MCA/PCA strokes, dehydration/rhabdo.

overall, 38 ED patients/22,000 participants (over 100 activated EMS, but many treated & refused transport); an overview of injury types

  • fractures
  • dislocations
  • effusions
  • heat injury
  • electrical injury
  • seizure
  • contusions/abrasions/lacs
  • dehydration
  • sprains/strains

SHOCK OBSTACLE (“Electroshock Therapy”, “Electric Eel”)

interesting notes about the rare folks who came in after this

  • tough to correlate causality, given they just went through an exhausting course before the last obstacle
  • website states as much as 10k vols (for reference, some tazers deliver 50k volts)
  • folks are wet (sweat, other obstacles)
  • troponin elevations have been documented in competitive exercise alone (e.g. marathons)

 

Please be careful at your next race, and keep an open mind with your next post-race patient.

References: annals article; picture

sweet smells, less pain

21 Apr

 Neat tip in April’s ACEP Now mag by Dr. Mell:

HIGHLIGHTS:

sweet-smelling  (e.g. cherry/blueberry/watermelon) lip balm coated the inside of a pediatric non-rebreather mask

letting patients pick the flavor gives them some small measure of control

some studies suggest sweet/pleasant odors may improve pain tolerance

works with oral solutions, seems like odors might work, too.

add it to the toolbox.

References: ACEP Now article; less pain with odors; less pain with sweets; picture.

 

 

quick H2-blocker reference

17 Apr

quick-reference chart put together for your use in a pinch.  I frequently found myself double-checking some of the generic/trade name crossover, and the IV/PO first-dosing at times, so figured this might be helpful for others as well.  Here it is, as a chart and photo.

 

h2

 

Generic Name Cimetidine Ranitidine Famotidine Nizatidine
Brand Name Tagamet Zantac Pepcid Axid
equivalent dosing (left-to-right)
PO (avg dose) 400mg 150mg 20mg 150mg
PO (big dose) 800mg 300mg 40mg 300mg
IV 300mg IV 50mg IV 20mg IV

 

References: UIC pharm referencegihealth patient education site