Clinical Pathway for Emergency Department Management of Diabetic Ketoacidosis and Hyperosmolar Hyperglycemic State February 18, 2020

Posted by Andy Jagoda, MD in: Uncategorized , add a comment

Click to review the Clinical Pathway for Emergency Department Management of Diabetic Ketoacidosis and Hyperosmolar Hyperglycemic State

Hyperglycemic emergencies – diabetic ketoacidosis (DKA) and the hyperosmolar hyperglycemic state (HHS) – are common presentations in the ED that require swift, specialized management strategies. Uncovering the precipitating event is critical to management, as morbidity and mortality are related more to the trigger than the DKA/HHS itself.

For patients presenting with suspected diabetic ketoacidosis (DKA) and the hyperosmolar hyperglycemic state (HHS) understanding of the etiology and pathophysiology will ensure optimal emergency management. Morbidity and mortality is most often due to the underlying precipitating cause, which may include infection, infarction/ischemia, noncompliance with insulin therapy, pregnancy, and dietary indiscretion.

Review this clinical algorithm for a clear and step-by-step outline for managing patients in ketoacidosis and hyperosmolar hyperglycemic state

Clinical Pathway for Emergency Department Management of Diabetic Ketoacidosis and Hyperosmolar Hyperglycemic State

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Need more information? Click here to review the course on Diabetic Hyperglycemic Emergencies: A Systematic Approach (Pharmacology CME).

An 8-year-old boy presents to the ED after falling at a local playground July 30, 2019

Posted by Anna in: Uncategorized , 2 comments

An 8-year-old boy presents to the ED after falling at a local playground. His mother, who was with him at the time of the injury, states that he was climbing out of a tree when he slipped and fell. He landed on his outstretched hands and is now complaining of right wrist pain. On examination, he has no open wounds, and he has a normal neurovascular examination, but he has an obvious deformity of his right forearm. The child describes his pain as 7/10.

You ponder how best to treat the child’s severe pain as quickly as possible….

What are your next steps?

Case Conclusion

To quickly address the 8-year-old boy’s arm pain, you ordered a dose of intranasal fentanyl at 1.5 mcg/kg. You instructed the nurse to draw up the IV formulation of fentanyl in a syringe and then attached an atomizer to the syringe. The nurse then administered half the dose into each of the patient’s nostrils. When you re-evaluated him 5 minutes later, his pain was significantly improved to 3/10. Eventually, the team was able to place an IV, and the boy’s fracture was successfully reduced while he was sedated with ketamine. The boy was discharged home, and dosing instructions for ibuprofen as needed for pain were given to his parents. You also provided a prescription for oxycodone for breakthrough pain, with specific instructions on its administration, storage, and disposal.

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Febrile Young Infants In the ED — How do you Manage them? July 11, 2019

Posted by Robin Wilkinson in: Uncategorized , 4 comments

Case Recap:
A 40-day-old girl presents to the ED in January for evaluation of a rectal temperature of 38˚C (100.4˚F). The history and physical examination are similar to an infant you saw in August, except that she has nasal discharge and a cough. Which risk stratification algorithm should you use for this infant? Would your workup change if a respiratory swab was positive for respiratory syncytial virus?

Case Conclusion:
Although the 40-day-old infant’s signs and symptoms were suggestive of a benign URI, you remembered that several studies demonstrated that infants in this age group (29-56 days) with documented RSV or influenza are still at risk for SBI, especially UTI, though the risk of IBI is lower in this age group compared with infants who have negative RSV or influenza testing. You ordered urine studies, blood culture, CBC, CRP, and PCT, given the non-negligible prevalence of IBI. The urinalysis was normal, the CBC showed a WBC of 10,000/mcL, the CRP was < 20 mg/L, the PCT was < 0.5 ng/mL, and the ANC was < 10,000 cells/mcL. Since the girl’s labs were reassuring and she was well appearing and feeding appropriately with reliable followup, you discharged her home without CSF testing and with close primary care follow-up the next day.

Did you get it right?

How geriatric physiology impacts clinical care April 30, 2019

Posted by Robin Wilkinson in: Uncategorized , add a comment

Just as “children are not little adults,” the physiologic and behavioral differences of the elderly demand that emergency clinicians manage illness in the elderly differently than we do in younger adults. In fact, two central medical principles used for children can be applied to the elderly: Patients are more vulnerable, and symptoms are much less specific.

There are unique issues involved in assessment and treatment of the elderly. Sir William Osler said, “In the old and debilitated, a knowledge that the onset of pneumonia is insidious and that the symptoms are ill-defined and latent should place the practitioner on his guard and make him very careful.” Osler’s statement holds true not only for pneumonia but also for nearly all diseases in the elderly.

“Textbook” symptoms are the exception rather than the rule in many cases with elderly patients. A behavioral change may be the only hint of an underlying infection. At least 75% of all episodes of functional decline in nursing home patients are due to infection. It is a common mistake to assume that a confused 80-year-old is “just suffering from dementia,” when in fact he or she may be a normally intact and independent person with acute delirium secondary to a UTI. Ask family members or caretakers about recent falls, anorexia, decreased activity, new incontinence, or confusion. (See table below.) These may be the only clues to a serious illness.

This information can help define the patient’s baseline functional and mental status. Five minutes on the telephone with the primary care provider or the patient’s daughter may prompt life-saving antibiotics instead of an inappropriate prescription for Haldol.

Enhance your assessment skills and management practices in elderly patients with the geriatric sessions at the 18th Annual Clinical Decision Making in Emergency Medicine conference in Ponte Vedra, FL – June 26-29, 2019.

Treatment Pathway for the Management of a Pediatric Patient With Hypothermia January 19, 2019

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Hypothermia occurs when the core body temperature falls below 35ºC (95ºF) due to primary exposure (eg, environmental exposure) or secondary to other pathologies. Infants, children, and adolescents are at higher risk for primary cold injuries due to a combination of physiologic and cognitive factors, but quick rewarming and appropriate disposition can result in survival and improved neurological outcomes. Treatment for cold injuries is guided by severity and can include passive or active measures.

This clinical pathway will help you improve care in the management of patients who preset with hypothermia. Download now

Treatment Pathway for the Management of a Pediatric Patient With HypothermiaTreatment Pathway for the Management of a Pediatric Patient With Hypothermia

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Case Conclusion — Shock in the Emergency Department March 6, 2014

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Recap of March’s Case: You are working in the ED late one evening when an 82-year-old man is brought in by his son. His son reports that earlier today, his father had been in his usual state of health, but this evening he found his father confused, with labored breathing. He is delirious and unable to answer questions. A focused physical examination demonstrates tachycardia without extra heart sounds or murmurs, right basilar crackles on lung auscultation, a benign abdomen, and 1+ lower extremity pitting edema. You establish intravenous access with a peripheral catheter and send basic labs. A further history obtained from the son reveals that his father has congestive heart failure with a low systolic ejection fraction, as well as a history of several prior myocardial infarctions that were treated with stent placement. As you consider this case, you ask yourself whether this patient is in shock, and if he is, what are the specific causative pathophysiologic mechanisms?

Case Conclusion: You rapidly determined that the patient was in shock. Although his blood pressure was within acceptable limits, he had clear clinical evidence of impaired end-organ perfusion as evidenced by altered mental status (impaired cerebral perfusion) and respiratory insufficiency. While you recognized the possibility of a cardiogenic process contributing to his presentation, the majority of the clinical data supported an infectious process (specifically, a right lower lobe pneumonia) resulting in a systemic inflammatory response and distributive pathophysiology due to septic shock. You administered a bolus of 30 mL/kg of lactated Ringer’s. You requested a comprehensive laboratory panel be sent, including CBC, chemistries and renal function analyses, arterial blood gas, serum lactate concentration, and blood cultures. You ordered a chest x-ray to better characterize his presumptive pneumonia. Because the patient was in shock due to sepsis, you ordered empiric broad-spectrum antibiotics based on your hospital’s antibiogram – in this case you elected to administer vancomycin 15 mg/kg (as the patient’s renal function is not yet known) and cefepime 2 gm IV. Despite these interventions, his blood pressure progressively decreased in the setting of an increasing temperature and worsening oxygenation. Given his clinical deterioration, you made the decision to intubate him and initiate mechanical ventilation with low-tidal-volume ventilation. Then, you placed a left subclavian central venous line and initiated a continuous infusion of norepinephrine, titrated for a MAP goal of > 65 mm Hg. His laboratory studies demonstrated leukocytosis (WBC 27 x 109/L), thrombocytopenia (90 x 109/L), acute renal failure (creatinine 3.1 mg/dL), and a lactic acidosis (lactate 7.2 mmol/L, bicarbonate concentration of 16 mmol/L, and base excess of -10 mEq/L). After receiving high-quality, evidence-based care in the ED, he was admitted to the MICU in critical condition, but ultimately made a full and uneventful recovery.

Thank you to everyone who participated in this month’s challenge!

Would you like to learn more about shock in the ED? Simply click the links below:

Cardiotoxicity January 29, 2014

Posted by Andy Jagoda, MD in: Uncategorized , 19 comments

Late one evening, a 32-year-old woman is brought to your ED via EMS after her boyfriend found her slumped over in a chair. He states that they were arguing last evening and that she was quite upset. Her boyfriend provides a medical history significant for migraine headaches, and he knows that she is taking verapamil for the same. Her fingerstick glucose is normal, and she has a heart rate of 28 beats/min and a blood pressure of 74/36 mm Hg. Consider what the best initial step in management for this patient would be — Is there a role for GI decontamination? What about hemodialysis?

Submit your diagnosis in the comments box below, and be sure to check back on February 8 to see if you were correct!

Case Conclusion — Urinary Retention Complications January 6, 2014

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Case 1:

A quick physical examination revealed only a distended bladder for the 72-year-old man. A urethral catheter was placed, and 700 mL of urine was obtained, with much relief for the patient. Not forgetting the patient’s presentation and his stumble while changing stretchers, you decided to perform a thorough neurological examination, and you found nearly absent rectal tone and absence of sensation and vibration below T11. Urgent MRI confirmed your diagnosis of spinal cord compression. You consulted neurosurgery, and the patient was admitted for decompressive laminectomy and eventual chemotherapy.

Case 2:

After taking the history of the 46-year-old febrile woman with HIV and giving her a thorough physical examination, you performed a rectal examination, which showed good rectal tone and no evidence of obstruction. You then performed a pelvic examination (with a chaperone present), and it showed vesicular lesions suggestive of herpes. Adequate pain control was achieved. Ultrasound showed a fully distended bladder. You gave the patient acetaminophen, IV acyclovir, and IV fluids, and you started cardiorespiratory monitoring. You performed complete bladder decompression using a 16F Foley and sent the urine for urinalysis and culture. The urinalysis returned positive for white blood cells, so you gave her IV ceftriaxone and admitted her to medicine for IV antibiotics, IV fluids, and antivirals.

Congratulations to this month’s winners!  You will receive a free copy of the latest issue of Emergency Medicine Practice: An Evidence-Based Approach To Emergency Department Management of Acute Urinary Retention. If you did not win this month, you can still read part of the issue — click here to download a free copy of this month’s Risk Management Pitfalls!

“Afebrile patient with a swollen knee…” Case Conclusion May 7, 2012

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The Conclusion Is…

You remembered from your evidence-based review of the literature that there is no serum blood test that can adequately rule out septic arthritis, so the patient’s history and exam warranted arthrocentesis. After laying the patient flat and partially flexing the knee with a pillow, you guided the needle medially under the patella and you aspirated watery, but cloudy, material. A point-of-care sLactate came back quickly at 15 mmol/L, and removed any ambiguity — this was a septic joint. While synovial culture and Gram stain (and blood cultures) were sent, along with sWBC and pre-op labs, you initiated IV antibiotics — vancomycin and ceftriaxone. Then you called up the orthopedist and asked him to prepare the OR.

Congratulations to  Dr. Lalitha, Dr. Averick, Dr. Karagöz, Dr. Piebalga, and Dr. Dube— this month’s winners of the exclusive discount coupon for Emergency Medicine Practice For an evidence-based review of the etiology, differential diagnosis, and diagnostic studies for Monoarticular Arthritis, purchase this issue.

Afebrile patient with a swollen knee… April 30, 2012

Posted by Andy Jagoda, MD in: Uncategorized , 27 comments

A middle-aged man with diabetes and hypertension has been waiting patiently to be seen, with a complaint of right knee pain and swelling that has gradually progressed over several hours. There is no history of trauma, recent or remote, but he describes several goutlike episodes of pain in both feet in recent years, which improved with rest and NSAIDs. He was triaged as an ESI4, and the waiting room is packed. Fortunately, the charge nurse comments on how uncomfortable he looks and he is brought into the ED for evaluation. The patient is afebrile, but the knee is hot, beefy red, and swollen. The ED is over-capacity and the patient’s history is reassuring, so you consider keeping him in a chair. But that knee looks impressive and you wonder if your plan is aggressive enough.

What do you do next?

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