1.3.19 Conference Summary

ED Pharmacology: Anti-epileptics - Brian Lauer, PharmD

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  • Pathophysiology

    • Seizure results from imbalance of excitatory and inhibitor neurotransmitters and failure of safety mechanisms

  • Emergent Therapy

    • Benzos: enhance GABA effect at post-synaptic GABA receptors

      • Lorazepam (IV): 0.1mg/kg (max 4mg), onset 5 min, duration 3 hrs

      • Midazolam (IM): 0.2mg/kg (max 10mg), onset in 5 min, duration 2 hrs; intranasal an alternative but less preferred

      • Diazepam (IV) 0.15mg/kg (max 10mg), onset 1-3 min, duration 15-30 min

    • Adverse effects: hypotension, respiratory depression (black box warning); diazepam associated with lactic acidosis; midazolam causes prolonged duration in renal insufficiency due to metabolite

    • RAMPART Trial: Lorazepam IV preferred over midazolam IM, though IV establishment took time —> so overall difference not significant

  • Maintenance Therapy

    • Fosfenytoin/phenytoin

      • Loading dose 20mg/kg, onset 15 min, duration 12-29 hrs, zero order kinetics

      • Fosphenytoin preferred for loading (more water soluble, can be administered faster, lacks preservatives), phenytoin for chronic therapy

      • Adverse effects: hypotension, arrhythmias, purple glove, hematologic effects, TEN/SJS, hepatotoxicity

      • Consider: checking level 1 hour after loading dose (especially in status epilepticus) and phenytoin dose adjustments for low albumin and renal failure (CrCl<10)

      • Toxicity includes nystagmus, ataxia, dysarthria, incoordination, coma, drug-induced seizures

    • Valproic acid

      • Sodium channel blocker; loading dose 20-40mg/kg (?max 3g), onset 60 min, duration 9-19 hrs

      • Adverse effects: hepatotoxicity, pancreatitis, thrombocytopenia, hyperammonemia (tx = levocarnitine), DRESS; worse outcomes in TBI pts, pregnancy category D, mitochrondrial disorders

    • Levetiracetam - tends to be 1st line

      • MOA not fully understood

      • Loading dose, 20-60mg/kg (max 4500mg), onset 30-60 min, duration 6-8 hrs

    • Lacosamide (restricted to neurology to iniitate)

      • Loading dose 200-400mg, onset 30-60 min, duration 13 hrs

      • Adverse effects: prolonged PR, Brady, DRESS,

    • Phenobarbital: binds GABA receptors, loading dose 20mg/kg, onset 15 min, duration 70-140 min, tends to cause more CNS depression, resp depression

    • ***Pregnancy: All are category D except Levetiracetum which is category C

  • AED monitoring - check level as well as trough

  • Continuous infusion AED (status)

    • Propofol: loading dose 1-2mg/kg —> 20mcg/kg/min (hypotension, rhabdo, metabolic acidosis, renal/cardiac failure)

    • Midazolam: 0.2mg/kg loading dose —> 0.05-2mg/kg/hr

    • Pentobarb: 5-15mg/kg —> 0.5-5mg/kg/hr

  • Aromatic Ring allergy (skin reaction)

    • aromatic ring-containing: carbemazepine, oxcarbazepine, phenytoin, lamotrigine

    • consider using non-aromatic ring AED ( valproic acid, levetiracetum) if allergy


Hepatobiliary Ultrasound - Dr. Jason Tehranisa

  • Indications

    • Jaundice, n/v, RUQ pain

    • Suspicion for: cholelithiasis, cholecystitis choledocholithiasis/biliary malignancy

  • Ultrasound basics:

    • Probe: curvilinear probe preferred (consider phased-array if ribs limiting view)

    • Positioning: supine; consider left lateral decubitus to help other abdominal structures fall out of the way

    • Probe placement: subcostal, epigastric, midclavicular, axillary

    • Image acquisition:

      • Long axis of gallbladder (often not the same at patient’s long axis)

      • Short axis (rotate 90 degrees)

      *** always fan all the way through, include view of gallbladder neck and CBD

http://www.em.emory.edu/ultrasound/ImageWeek/Abdominal/mickey_mouse.html

http://www.em.emory.edu/ultrasound/ImageWeek/Abdominal/mickey_mouse.html

  • Ultrasound anatomy

    • Exclamation point (gallbladder + portal vein below the GB neck)

    • Portal triad (Mickey Mouse sign): larger portal vein deep to CBD and hepatic artery

      • CBD normally on left; use color flow to identify (no flow)

    • Measurements

      • GB wall: <3mm is normal (always measure anterior wall)

      • Common bile duct: internal diameter<6mm (every decade above 60 yrs can increase by 1mm)

gallstones long.gif
  • Cholelithiasis

    • POCUS by ED providers: sensitivity 89.8%, specificity 88.0%

    • Fan all the way through to visualize gallbladder neck

    • Stones are hyperechoic with posterior shadowing, mobile

    • Sludge appears as echogenic layer at posterior aspect of gallbladder

    • Pitfalls: GI mimic - bowel may appear similar to stone (but without posterior shadowing) —> try to reposition patient to have bowel fall out of the way

    • WES (wall echo shadow) sign: hyperechoic arch (near wall) with posterior echoes followed by posterior shadowing deep to the wall, disrupting normal gallbladder anatomy view; indicates contracted gallbladder filled with stones

cholecystitis.jpg
  • Acute cholecystitis

    • Sensitivity 88%, specificity 87% (POCUS by ED providers compared to radiology US)

    • Stones and sonographic Murphy’s sign most sensitive; also pericholecystic fluid, gallbladder wall thickening (>3mm) may occur later

    • Pitfall: uniform hypoechoic line surrounding gallbladder likely normal but mimics pericholecystic fluid

The POCUS Atlas

The POCUS Atlas

  • Choledocholithiasis

    • Gallstone in CBD, often associated with transaminitis/pancreatitis/cholecystitis; can occur after cholecystectomy

    • US findings: up to 6mm diameter is normal, >1cm is abnormal



Shoulder Ultrasound - Dr. Ben Boswell

  • Probe: curvilinear or linear

  • Technique: ‘‘front-to-back’ approach, long and short axis, position is key

Injuries evaluated with ultrasound

  • Biceps tendon

    • Head of biceps is well-defined hyperechoic circular structure over humeral head in biceps groove

    • Injury can result in inflammation in this area —> look for fluid or loss of normal hyperechoic biceps head

https://clinicalgate.com/shoulder-ultrasound/#s0020

https://clinicalgate.com/shoulder-ultrasound/#s0020

Biceps tendon tear

Biceps tendon tear

  • Rotator cuff — subscapularis, supraspinatus, infraspinatus, teres minor

    • Llook for disruption of tendon in long and short axis

    • Supraspinatus: uniform arch over humeral head

      • Most common rotator cuff tear

      • Synovial capsule: hypoechoic stripe smooth arch over hyper echoic bone is normal, not pathologic

Supraspinatus (normal short axis) https://theultrasoundspace.co.uk

Supraspinatus (normal short axis) https://theultrasoundspace.co.uk

Subcapsularis (normal) msksono.com

Subcapsularis (normal) msksono.com

Subscapularis Tear

Subscapularis Tear

  • AC Joint Injury (‘shoulder separation’

  • Shoulder dislocation - anterior most common

    • Place probe posteriorly with probe marker toward patient left

    • Inability to rotate arm indicates dislocation

    • Look for humeral head in glenoid **great for post-reduction confirmation

Normal shoulder

Normal shoulder

Anterior dislocation, humeral head displaced farther from the probe

Anterior dislocation, humeral head displaced farther from the probe

CPC - Dr. Andy Veverka, Dr. Chris Miller

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  • 60s yo M presenting s/p new onset seizure, altered, hypertensive to 190s, mildly tachycardic

    • PMH including hypertension, sickle cell, CKD

    • Seen in ED a few days prior for headache, n/v then returned after blunt trauma hrs later; overall workup included neg CTH x2, LP w/ pleocytosis

  • Diagnostic test of choice: MRI

  • Diagnosis: PRES (Posterior Reversible Encephalopathy Syndrome)

    • Common sx: AMS, seizure, headache, visual disturbance

    • Risk factors: HTN, renal failure, SLE, immunocompromised, eclampsia

    • Treatment: ABCs, AEDs, blood control

    • Prognosis: symptoms usually resolve with BP control and addressing inciting factor; in some cases, neurologic symptoms may persist

    • Several reported cases of sickle cell and PRES


EBM: RSI - ‘Roc vs Sux’ - Dr. Lori Shannon

  • Succinylcholine

    • Depolarizing neuromuscular blockade

    • Dose: 1-1.5mg/kg

    • PK: onset 45-60 sec, duration 5-10 min, rapidly cleared by plasma cholinesterase

    • Pros: Faster onset, shorter duration (allows for repeat neuro exam)

    • Cons: short duration, contraindications (neuromuscular disorders, renal failure, burns, crush injuries), multiple adverse effects (inc K, malignant hyperthermia, inc ICP, etc)

  • Rocuronium

    • Non-depolarizing neuromuscular blockade

      • 0.6-1.2mg/kg

      • PK: onset 1-2 min, duration 30-60 min, hepatic/renally cleared

      • Pros: no contraindications (except anaphylaxis), long duration (if desired), reversal agent (sugammedex)

  • Evidence favoring succinylcholine

    • Literature support… several large studies/reviews (including Cochrane Review) demonstrating succinylcholine superior to rocuronium for achieving excellent intubating conditions; fewer studies for roc and many OR-based

    • Faster onset of paralysis, thus helping optimize intubating conditions

    • Prolonged paralysis (associated with Roc) can lead to poor post-intubation sedation

    • Limited evidence that succinylcholine causes hyperkalemic arrhythmias

    • Short duration allows for more frequent neuro checks

  • Evidence favoring rocuronium

    • No side effects

    • With correct dosage, no significant difference between roc and sux for intubation success/conditions

    • Increased time of paralysis is an advantage in the ED

    • Fasciculations caused by succinylcholine increase oxygen consumption leading to more rapid desaturation (including general and overweight pts)