Nebulized Lidocaine

KEY POINTS:
--not a ton of evidence for use, but sounds cool, probably safe (in the appropriate non-toxic dose)
--reminder: max dose of lidocaine (without epinephrine) = 4.5mg/kg

ASTHMA/COPD:
--some benefit in daily long-term therapy for asthma, but doesn't apply to us in the ED
--lidocaine can cause bronchospasm in asthmatics, so one study pretreated with albuterol
--one study's sample dose: 1ml of 1% lido in 4 ml NS
--may be useful for cough suppression

NG TUBE PLACEMENT (in kids):
--apparently, not much proof that it helps or makes it less painful

Reference(s): asthma long-term, cough suppression, more cough suppression, ng tube, more ng tube

Lidocaine pretreatment during intubation

CONCEPT:
--intubation is associated with transient increase in BP & heart rate, due to brief catecholamine surge after messing with the larynx (probably)
--this surge can result in increased ICP, which is not great for head injury/head bleed patients
--lidocaine pretreatment can help blunt the rise in ICP

EVIDENCE:
--lidocaine shown to blunt increased ICP during endotrach suctioning, but may not directly apply to ED setting (rapid sequence intubation)
--review (linked below) "could find no evidence that in acute traumatic head injury pretreatment with IV lignocaine/lidocaine before a RSI reduces ICP or improves neurological outcome"

10-SECOND TAKEAWAY:
--RSI may cause brief increase ICP
--lidocaine pretreat (1.5mg/kg) for RSI supposed to help blunt this response
--not exactly a mountain of proof this works

QUICK TANGENT:
--fentanyl might be an alternative (1-3mcg/kg), if the BP can handle it

Reference(s): our canadian bretheren, review article, uptodate: "Pretreatment agents for rapid sequence intubation in adults"

Sgarbossa Criteria (Acute MI in LBBB)

KEY POINTS:

--Sgarbossa criteria help look for STEMIs in people with LBBB (left bundle branch block)

ECG CRITERIA:
5 pts - concordant (same direction as QRS complex) ST elevation >=1mm any lead
3 pts - ST depression >=1mm in anterior leads (V1, V2, V3)
2 pts - discordant (opposite direction of QRS) ST elevation >=5mm any lead

--add up the points, score >=3 is 90+ percent specific for an MI
--the discordant ST elevation is apparently less useful

HOW DO I USE THIS?:
--you're handed an EKG, there's a LBBB

--look for >=1mm concordant ST elevation
--look for ST depression in anterior leads

--if you see these things, worry about an MI

Reference(s): THE article, nice website

Mono (a.k.a. Infectious Mononucleosis)

HPI:
--If they read the textbook, they come in with: fever, pharyngitis, adenopathy, fatigue, and atypical lymphocytosis, +/- splenomegaly.

DIAGNOSIS:
--Monospot test is helpful, doesn't take forever to get
--EBV (Epstein-Barr Virus) stuff

SOMETHING I (re)LEARNED RECENTLY:
--Elevated LFTs (liver function tests): very common in mono, but are self-limited
--If you have a pt with pharyngitis/feeling crappy, with elevated LFTs, let mono float through your differential

TREATMENT:
--supportive, symptomatic
--steroids controversial

GOOD ADVICE FOR PATIENTS:
--no contact sports for 3-4 weeks (highest risk of spontaneous or traumatic splenic rupture most likely 2-21 days after onset of symptoms)

Reference(s): Aronson MD, et al. Infectious mononucleosis in adults and adolescents. UpToDate.com

Postpartum Preecclampsia

Key Points:

--Postpartum preeclampsia = HTN and proteinuria after delivery

--can occur up to 4 weeks after delivery (median of 5 days in this study)

--33-69% of patient have no evidence of preeclampsia in the ante/peripartum period

--HPI: most common complaints (n=22):

• headache (82%, 18/22)
• visual changes (31 %)
• elevated BP at home (23%)
• nausea (18%)
• abdominal pain (14%)
• vomiting (14%)
• edema (9%)
• neck pain (9%)

--PHYSICAL EXAM & LABS: notable findings, some not as 'classic' as you think (n=22 unless indicated)

• elevated SBP (95%)
• elevated DBP (77%)
• hyperreflexia (47%, 10/21)
• edema (84%, 16/19)
• proteinuria (64%)
• elevated LFTs (41%)
• hyperuricemia (54%)

--TREATMENT:

• BP control (e.g. hydralazine, labetolol)
• magnesium, benzodiazepines if seizures

10-SECOND TAKEAWAY:
--Postpartum preecclampsia (classically) = HTN, proteinuria, <4wks postpartum
--Symptoms: high BP, HA, vision changes, nausea/vomiting, swelling
--Good to check (but all don't have to be abnormal): BP, reflexes, urine (proteinuria), LFTs, uric acid
--Treatment Toolbox: can't deliver postpartum, so BP control and magnesium/benzos if ecclamptic

Reference(s): Yancey et al. Postpartum Preeclampsia: Emergency Department Presentation and Management. JEmergMed 2008.

Submitted by T. Boyd.

Acute Chest Syndrome (Sickle Cell Crisis)

Key Points:

--Acute chest syndrome (chest pain, hypoxia, decreasing Hb levels, multi-lobar pneumonia on CXR) is the leading cause of death amongst patients with sickle cell disease.

--Vichinsky et al.: 30 center study, 671 episodes of the acute chest syndrome in 538 patients with sickle cell disease

• 72% of patients were initially admitted with another diagnosis (e.g. pain), then diagnosed with acute chest syndrome 2.5 days later (on average). 
• Most common symptoms:
• fever (80%)
• cough (62%)
• chest pain (44%)
• tachypnea (45%)
• SOB (41%)
• extremity pain (37%)
• abdominal pain (35%)
• rib/sternal pain (21%)
• Mortality mostly due to respiratory failure from pulmonary emboli (marrow, fat, or thrombosis) and pneumonia.

Treatment:
--broad antibiotics (including a macrolide)
--bronchodilators (assume airway hyperreactivitiy even if no wheezing)
--early transfusions for patients at high risk of complications.

10-SECOND TAKEAWAY:
--Sickle Cell + cardio/pulm complaints: think about Acute Chest Syndrome
--Symptoms: non-specific
--PE's and pneumonias suck
--Treatment Toolbox: antibiotics, bronchodilators, transfusions

Reference(s): Vichinsky EP, et al. Causes and outcomes of the acute chest syndrome in sickle cell disease. National Acute Chest Syndrome Study Group. N Engl J Med. 2000 Jun 22;342(25):1855-65.

Submitted by T. Boyd.