Angioedema (quick review)

WHAT IS IT?:
--soft tissue swelling, from the release of inflammatory mediators that cause dilation and increased permeability

--affects head/neck commonly (mouth/tongue/throat is bad for airway); bowel wall causing abdominal pain.

--generally develops over minutes to hours and resolves in 24 to 48 hours

CAUSES:

--allergic/mast cell mediated

--hereditary/Deficiency of C1 (complement protein) inhibitor

--drug related (classically ACE inhibitors , but seen with other meds too—e.g. ARBs, NSAIDs, aspirin, calcium channel blockers)

--rare: occurs in only 0.1 to 0.7 percent of patients treated with an ACE inhibitor; half these cases within 1 week of starting the med, but can occur years later;

--38% idiopathic (no trigger identified)

TREATMENT TOOLBOX:

--ABC’s

--stop the drug (if ACE inhibitor related, etc)

--allergic reaction meds: antihistamines, steroids, epinephrine (efficacy not proven, may not work if not mast cell mediated)

--FFP (fresh frozen plasma) a possibility (complement?)

10-SECOND VERSION:

--angioedema: things swell; airway swelling = not awesome

--from allergic reaction, complement deficiency, ACE I's or other drugs, or idiopathic

--treatment options: airway, antihistamines, steroids, epi, FFP

 Reference(s): uptodate.com 'an overview of angioedema'

how to counsel patients with miscarriage

WHY IT MATTERS:

--We see so many pt's in ED who come with first trimester vaginal bleeding.

--For us, it is an easy workup, basically, our question is ectopic or not...
--...but for them, the question is: Is there anything I could have done, or that the doctors can do to save the pregnancy?
 

KEY POINTS:

--Studies show, nothing helps:

• not steroids
• not pelvic rest
• not bed rest
• not beta HCG injections
• not horomnes (progestogen)
• not anticoagulation

--So, you can reassure your patients that nothing they did caused this, and there is nothing they can do to make it go on to a successful pregnancy or not. It will just do what it will do. If first trimester pregnancy does result in miscarriage, often these are chromosomal abnormalities (about 57%).

--Fortunately, if you can see an IUP on ultrasound with fetal cardiac activity, 85% of these women with early pregnancy and vaginal bleeding or abdominal pain will carry to full term.

--Heavy bleeding (more than regular menses) is associated with higher pregnancy loss, but spotting is likely to go on to a normal pregnancy.

10-SECOND RECAP:

--first trimester bleeding: ddx starts with ectopic, then miscarriage (threatened or otherwise)

--spotting is better than heavy bleeding

--reassure patients that there's nothing to do, its not their fault; not much really seems to change outcome (miscarriage vs. not)

--reassure patients with ultrasound: +IUP with fetal cardiac activity, 85% will carry to term

Submitted by R. Morris.  

Reference(s): fetal cardiac activity, ultrasound, aspirin or anticoagulants, progestogen, bed rest, first trimester bleeding, threatened miscarriage, chromosome abnormalities, picture

women more empathetic than men, study says

here's a low impact tibit, in honor of the thanksgiving holiday...

RANDOM TANGENT:
--study of 248 3rd year med students, rated by their patients after standardized patient encounters

--women seem more empathetic: scored higher than men on 3 measures of empathy
--asian american students scored lower than white students


BOTTOM LINE:
--as an asian, male physician, should i be worried?

Reference(s): Berg K, et al. Medical students' self-reported empathy and simulated patients' assessments of student empathy: an analysis by gender and ethnicity

What is the Synovial WBC cutoff in Septic Arthritis?

GOOD QUESTION:
--so you're worried about a septic joint
--you've tapped it, now the results are back...


UPTODATE.COM:
--suggests WBC 15,000-100,000/mm3, PMNs >75% for likely septic arthritis


REVIEW ARTICLE 1:
KEY POINTS:
--recent joint surgery or cellulitis over a prosthetic joint were the only findings on H&P that significantly alter the probability of nongonococcal septic arthritis


--positive likelihood ratios with synovial white blood cell (sWBC) counts of...

• 0 to 25,000 WBC per mm3 (or uL): +LR = 0.33
• 25,000 to 50,000: 1.06
• 50,000 to 100,000: 3.59
• >100,000: infinity 

--their conclusion: synovial WBC (>50,000/mm3--if I've done the conversion correctly) can increase, but not decrease, the probability of septic arthritis


REVIEW ARTICLE 2:
KEY POINTS:
--most common associated symptoms (found in >50% of patients): joint pain, joint swelling, fever


--positive likelihood ratios with synovial white blood cell (sWBC) counts of...

• <25,000/microL: LR 0.32
• >25,000/microL: LR, 2.9
• >50,000/microL: LR, 7.7
• >100,000/microL: LR, 28.0 

--synovial WBC differential mattered too: >90% PMNs, LR 3.4; <90% PMNs, LR 0.34

BOTTOM LINE:
--synovial WBC >25k/mm3 is suspicious
--synovial WBC >50k/mm3 very suspicious
--synovial WBC >100k/mm3 don't think too hard
--lots of PMNs (75%+) on the diff, don't think too hard either

Reference(s): review article 1, review article 2, uptodate.com

Magnesium Sulfate (quick refresher)

ECCLAMPSIA:
--dose: 4-6 grams IV over 15 min, 1-2 g/hour infusion s/p

ASTHMA:
--dose: 2 grams IV over 15 min

TORSADES:
--dose: 1-2 grams IV over 15 min (or faster, if coding)
--peds dose: 25-75mg/kg

POSSIBLE SIDE EFFECTS:
--heart block (slows SA node impulse & prolongs conduction time)
--hyporeflexia
--respiratory depression
--CNS depression
--vasodilation/flushing/hypotension (rate related)

10-SECOND VERSION:
--magnesium sulfate, worth a shot in ecclampsia, torsades, refractory asthma, refractory death (ACLS option), hypomag
--dosing: 2 g IV for most (25-75mg/kg up to 2g max for kids), a little more for (4-6 g) for seizing patients, best if over 15 minutes
--test/pimping question: side effects/toxicity indicated by resp/CNS depression, hyporeflexia

Reference(s): http://www.uptodate.com/

Vittles for Contemplation

FYI/E:
--Emergency Physicians Monthly had an interesting article in last month's issue that made me think more than usual, figure I'd call some attention to it for those that might've missed it.

LINK:
--http://www.epmonthly.com/features/current-features/between-a-rock-and-a-hard-place/

10-SECOND VERSION:
--guy with hx CAD is getting a belly CT, complains of itching, then SOB/throat tightness, and ECG looks like a STEMI. what now? epi? cath lab? change your scrubs?
--i think i've eventually come to terms with what I'd do (won't tell you, will let y'all ponder a bit), but makes you think, no?

Reference(s): http://www.epmonthly.com/

Nasogastric Lavage in GI Bleeding

WHY DOES THIS MATTER?:

--GI Bleeding can be from an upper or lower source
--consultants/admitting physicians may ask you to place an NG tube and lavage the stomach to help differentiate upper vs. lower GI bleed, if unclear from presentation

DOES IT REALLY HELP?
--2010 review: analysis of 3 limited studies to eval this question: "does nasogastric aspiration and lavage in patients with melena or hematochezia and no hematemesis differentiate an upper from lower source of gastrointestinal (GI) bleeding?"

--prevalence of an upper GI source was 32% to 74%
--sensitivity 42-68%
--specificity 54-91%
--positive predictive value (PPV) 41-93%
--negative predictive value (NPV) 61-78%
--complication rates of NG tube insertion 1.6%.                            

BOTTOM LINE:
--low sensitivity, poor NPV, variable specificity & PPV
--NG lavage has limited diagnostic utility for GI bleed source

Submitted by T. Boyd.

Reference(s): Palamidessi N, et al. Nasogastric Aspiration and Lavage in Emergency Department Patients with Hematochezia or Melena Without Hematemesis.  Acad Emerg Med. 17 (2); Jan 2010, picture

Clonidine Overdose

WHY IT MATTERS:

--Clonidine is a common medication in many households, adults are taking it, children can get into it, with minimal amounts causing sedation and AMS. 

MECHANISM:

--alpha-2 agonist

SYMPTOMS:
--respiratory depression
--miosis (small pupils)
--bradycardia
--hypotension
--somnolence

TREATMENT:
--Symptoms usually resolve in 24 hours; deaths are rare with most treatment being supportive care.   
--Naloxone can reverse this in some cases and is worth a try in opioid naive children. Use between 0.4mg to 10mg with larger doses for evaluation of any effect.


10-SECOND RECAP:
--clonidine overdose can happen
--its an alpha-2 agonist
--looks a bit like opiate toxidrome (sleepy, respiratory depression, small pupils, etc.)
--narcan/naloxone might be worth a try (0.4mg IV and more PRN, titrate to effect)

Submitted by T. Boyd.

Reference(s): Goldfrank’s Toxicologic Emergencies 8th ed. page 948-9, picture

Acute Cholangitis

OVERVIEW:
--Acute cholangitis is a clinical syndrome resulting from stasis and infection in the biliary tract. 
--The most important predisposing factor for acute cholangitis is biliary obstruction and stasis, generally secondary to biliary calculi or a stricture.

CHARCOT'S TRIAD: 
--Fever (90%), RUQ pain (70%), and Jaundice (60%)
--As a whole only 50%-70% of cases possess all three

REYNOLD'S PENTAD:
--Same as above (fever, jaundince, RUQ pain) + AMS (10-20%) and hypotension (~30%)
--occurs in suppurative cholangitis, a more severe form of cholangitis with higher morbidity/mortality.

BACTERIA:
--E. coli, Enterococcus, Klebsiella, Enterobacter, and Anaerobes.

DIAGNOSIS:
--Charcot’s triad
--2/3 of Charcot’s triad + elevated liver enzymes + biliary dilatation based on the Tokyo Guidelines for diagnosis.

IMAGING:
--CBD dilatation is a common finding; RUQ ultrasound is the recommended first imaging test.
--After RUQ u/s, ERCP or MRCP to confirm diagnosis and intervene therapeutically with sphincterotomy, stone extraction, or stent insertion.

ANTIBIOTICS:


Zosyn OR Ancef
Meropenam
Ceftriaxone AND Flagyl
Ciprofloxacin AND Flagyl --80% of patients respond to conservative therapy with antibiotic therapy. Biliary drainage is emergently required in the remaining 20% (ERCP/MRCP).


10-SECOND RECAP:
--Acute cholangitis: biliary tract infection, usually 2/2 obstruction
--Charcot's Triad: fever, jaundice, RUQ pain
--Reynold's Pentad: charcot's + AMS, hypotension
--Diagnosis: hx, labs/LFTs, RUQ u/s, ERCP/MRCP
--Treatment: antibiotics, ERCP/MRCP

Submitted by J. Grover.

Reference(s): Yusoff IF, Barkun JS, et al. "Diagnosis and management of cholecystitis and cholangitis." Gastroenterol Clin N Am 32 (2003) 1145–1168, Uptodate. "Acute Cholangitis," image