Emergency Medical Minute

Explore the intriguing statistics on the recurrence of unprovoked seizures in children. The discussion highlights that the risk increases significantly over time, with 30% at four months. Factors like age under three and initial seizure presentation play crucial roles. This vital information aids in guiding families on follow-up care and prognosis, ensuring they are well-informed about their child's health.

Author: Gretchen Hinson, M.D. Educational Pearls: Controversial topic. Pathophysiology - acidosis leads to an extracellular potassium shift. Patients in DKA will be intracellularly potassium deplete, but will have a falsely normal/elevated serum potassium. 3 risk of giving bicarb in DKA - alkalosis will drive potassium intracellularly but can overshoot (hypokalemia) and increase risk of arrhythmias; bicarb slows clearance of ketones and will transiently increase their precursors; bicarb can cause elevated CSF acidosis. 3 instances when appropriate to give bicarb in DKA: DKA in arrest; hyperkalemic in DKA with arrhythmia; fluid and vasopressor refractory hypotension. References: Bratton, S. L., & Krane, E. J. (1992). Diabetic Ketoacidosis: Pathophysiology, Management and Complications. Journal of Intensive Care Medicine, 7(4), 199-211. doi:10.1177/088506669200700407 Chua, H., Schneider, A., & Bellomo, R. (2011). Bicarbonate in diabetic ketoacidosis - a systematic review. Annals of Intensive Care, 1(1), 23. doi:10.1186/2110-5820-1-23

Author: Alicia Oberle, MD Educational Pearls: Recent study has shown risk factors for return included patients at high risk for resistance (nursing home, obstructive uropathy), patient where diagnogsis of pyelonephritis was missed, but the biggest risk factor was the existence of bug-drug mismatches. Cephalexin (Keflex) was associated with highest rate of return, while nitrofurantoin (Macrobid) was associated with lowest return rate. Recommendation is to continue to detect between pyelonephritis and cystitis, broaden coverage for patients with complications, and utilize your facilities antibiogram. References: Jorgensen S, et al. ( 2018). Risk factors for early return visits to the emergency department in patients with urinary tract infection. American Journal of Emergency Medicine. 36(1):12-17

Author: Aaron Lessen, M.D. Educational Pearls: There is currently debate within the medical community about what constitutes cardiac activity on ultrasound in the setting of cardiac arrest. A recent study has shown there providers looking at the same clips from an echo will disagree about what constitutes cardiac activity. Some of the confusion stems from movement that is not cardiac in etiology. For example, some alvular movement can be due to IV fluids and some cardiac motion can be due to the patient being bagged. Cardiac activity is defined as "Any intrinsic motion of the myocardium." However, even if this is present, it is important to ask if it clinically significant cardiac activity. Despite disagreement, ultrasound can be useful for clinical decision making. References: Gaspari R et al. (2016) Emergency Department Point-Of-Care Ultrasound in Out-Of-Hospital and in-ED Cardiac Arrest. Resuscitation; 109: 33 – 39. Hu K et al. (2017) Variability in Interpretation of Cardiac Standstill Among Physician Sonographers. Ann Emerg Med.

Author: Peter Bakes, M.D. Educational Pearls: Rare disease with 1-2 patients out of 100,000. About 60% of patients report a preceding diarrheal illness and classically presents with an ascending motor weakness. Pathophysiology is likely due to molecular mimicry where the immune system creates antibodies against a pathogen (C. jejuni ) which appears similar to the myelin of peripheral nerves resulting in autoimmune demyelination. Diagnosis is made by clinical presentation +/- a spinal tap with a characteristic high protein count but without cells. Treatment is IVIG or plasmapharesis. It is important to monitor respiratory function because about 15% of patients progress to respiratory failure. References: Sejvar, James J.; Baughman, Andrew L.; Wise, Matthew; Morgan, Oliver W. (2011). "Population incidence of Guillain–Barré syndrome: a systematic review and meta-analysis" van den Berg, Bianca; Walgaard, Christa; Drenthen, Judith; Fokke, Christiaan; Jacobs, Bart C.; van Doorn, Pieter A. (15 July 2014). "Guillain–Barré syndrome: pathogenesis, diagnosis, treatment and prognosis". Nature Reviews Neurology. 10 (8): 469–482. Yuki, Nobuhiro; Hartung, Hans-Peter (14 June 2012). "Guillain–Barré Syndrome". New England Journal of Medicine. 366 (24): 2294–2304.

Author: Nick Hatch, M.D. Educational Pearls Tramadol acts at multiple receptors and is a partial agonist at the mu opioid receptor, but also blocks reuptake of serotonin and norepinephrine throughout the body among others. One major side effect to be aware of is that it lowers the seizure threshold. Useful in setting of pain control in patients with contraindications to NSAIDs who are poor opioid candidates. Use with caution as it potential for abuse. References Hennies HH, Friderichs E, Schneider J (July 1988). "Receptor binding, analgesic and antitussive potency of tramadol and other selected opioids". Arzneimittel-Forschung. 38 (7): 877–80. "Tramadol Hydrochloride". The American Society of Health-System Pharmacists. Retrieved Dec 1, 2014. "Withdrawal syndrome and dependence: tramadol too". Prescrire Int. 12 (65): 99–100. 2003

Author: Aaron Lessen, M.D. Educational Pearls A "stuffer" is a term for someone who hastily and conceals a bag of drugs orally/rectally/vaginally in an unplanned situation. A "packer" is someone who is planning to smuggle drugs, and does so in a similar manner. "Stuffers"are more likely to have the drug container open up in their system, while packers tend to have more reliable containment, but typically have larger quantities on-board. Be on look out for symptoms associated with the drug's exposure (drug dependent) as well as mechanical symptoms (perforation; obstruction). If suspicious, order CT as X-rays underestimate severity. Management: treat symptoms of intoxication appropriately, observe if packets are intact, consider surgery/endoscopy if necessary. References Dueñas-Laita A, Nogué S, Burillo-Putze G (2004). "Body packing". New England Journal of Medicine. 350 (12): 1260–1 Hergan K, Kofler K, Oser W (2004). "Drug smuggling by body packing: what radiologists should know about it". Eur Radiology. 14 (4): 736–42. Traub SJ, Hoffman RS, Nelson LS (2003). "Body packing—the internal concealment of illicit drugs". New England Journal of Medicine. 349 (26): 2519–26.

Author: Dylan Luyten, MD Educational Pearls Johannes Hoffer coined term Nostalgia in 1688 in his medical dissertation. Nostalgia was a formal medical diagnosis, and one that dates back to 17th century when soldiers had longing for home and melancholy with a constellation of symptoms including lethargy, sadness, disturbed sleep, heart palpitations, GI complaints, and/or skin findings for which the only cure was to return home. In the civil war, over 5000 soldiers were given medical leave for nostalgia. Always remember to view your patient in the appropriate context (psychosocial, cultural, historical, etc.) References Beck, J. (2013, August 14). When Nostalgia Was a Disease. Retrieved March 08, 2018, from https://www.theatlantic.com/health/archive/2013/08/when-nostalgia-was-a-disease/278648/

Author: Dylan Luyten, M.D. Educational Pearls The Lazarus phenomenon is the delayed return of spontaneous circulation after cessation of CPR. A prospective study in Finland found 5 out of 840 patients where CPR was attempted in the setting of cardiac arrest experienced the Lazarus effect (about 0.6%). 3 of these patients died on scene, and the other 2 died in the hospital at 1.5 and 26 hours respectively. Ultimately, the Lazarus effect is rare, but it does occur and providers and family members should be aware that signs such as gasping or twitching may be seen after cardiac arrest, but the prognosis is still dismal. References Kuisma, M, et al. (September 2017) "Delayed return of spontaneous circulation (the Lazarus phenomenon) after cessation of out-of-hospital cardiopulmonary resuscitation". Resuscitation. 118: 107-111

Author: Jared Scott, M.D. Educational Pearls Flu is widespread throughout the US (through Jan 20th 2018). All age groups have seen surge in hospitalizations, but 65 + age group has seen the largest surge in hospitalizations due to flu. New recommendations for treating with Tamiflu! Treat the following high-risk groups at any stage of illness: Children under age 2, Adults 65 and older, patients with comorbidities such as chronic lung disease, heart disease, blood disorders, kidney disorders, liver disorders, neurological disorders, immunosuppressed, pregnant women, American Indians, extreme obesity, women under 19 on long-term aspirin, and nursing home residents. References: https://www.cdc.gov/flu/about/disease/high_risk.htm https://www.cdc.gov/flu/weekly/summary.htm