Brit Long

The emergency medicine management of severe alcohol withdrawal

Introduction Alcohol use is widespread, and withdrawal symptoms are common after decreased alcohol intake. Severe alcohol withdrawal may manifest with delirium tremens, and new therapies may assist in management of this life‐threatening condition. Objective To provide an evidence‐based review of the emergency medicine management of alcohol withdrawal and delirium tremens. Discussion The underlying pathophysiology of alcohol withdrawal syndrome (AWS) is central nervous system hyperexcitation. Stages of withdrawal include initial withdrawal symptoms, hallucinations, seizures, and delirium tremens. Management focuses on early diagnosis, resuscitation, and providing medications with gamma‐aminobutyric acid (GABA) receptor activity. Benzodiazepines with symptom‐triggered therapy have been the predominant medication class utilized and should remain the first treatment option with rapid escalation of dosing. Treatment resistant withdrawal warrants the use of phenobarbital or propofol, both demonstrating efficacy in management. Propofol can be used as an induction agent to decrease the effects of withdrawal. Dexmedetomidine does not address the underlying pathophysiology but may reduce the need for intubation. Ketamine requires further study. Overall, benzodiazepines remain the cornerstone of treatment. Outpatient management of patients with minimal symptoms is possible. Conclusions Alcohol withdrawal syndrome can result in significant morbidity and mortality. Physicians must rapidly diagnose these conditions while evaluating for other diseases. Benzodiazepines are the predominant medication class utilized, with adjunctive treatments including propofol or phenobarbital in patients with withdrawal resistant to benzodiazepines. Dexmedetomidine and ketamine require further study.

Clinical Mimics: An Emergency Medicine-Focused Review of Stroke Mimics

BACKGROUND Stroke is a leading cause of death and disability and most commonly presents with focal neurologic deficit within a specific vascular distribution. Several other conditions may present in a similar manner. OBJECTIVES This review provides emergency providers with an understanding of stroke mimics, use of thrombolytics in these mimics, and keys to differentiate true stroke from mimic. DISCUSSION Stroke has significant morbidity and mortality, and the American Heart Association emphasizes rapid recognition and aggressive treatment for patients with possible stroke-like symptoms, including thrombolytics. However, many conditions mimic the presentation of stroke, with up to a 31% rate of misdiagnosis, leading to potentially harmful treatment. Stroke mimics are conditions that present with stroke-like symptoms, including seizures, headaches, metabolic, infection, space-occupying lesion, neurodegenerative disorder, peripheral neuropathy, syncope, vascular disorder, and functional disorder. Factors of history and physical examination supporting stroke vs. mimic are discussed, though any sudden-onset, objective, focal neurologic deficit in a patient should be assumed acute stroke until proven otherwise. Head computed tomography noncontrast is the first-line imaging modality. Magnetic resonance imaging is the most sensitive and specific imaging modality. Neurology consultation is recommended in the majority of patients. If stroke is suspected after evaluation, shared decision-making for further management and consideration of thrombolytics is recommended. CONCLUSIONS Stroke mimics present a conundrum for emergency providers. A new focal neurologic deficit warrants rapid evaluation for stroke with neuroimaging and neurology consultation. Several mimics found on assessment may resolve with treatment.

Ready for Prime Time? Biomarkers in Sepsis

Sepsis is a common condition managed in the emergency department. Current diagnosis relies on physiologic criteria and suspicion of a source of infection using history, physical examination, laboratory studies, and imaging studies. The infection triggers a host response with the aim to destroy the pathogen, and this response can be measured. A reliable biomarker for sepsis should assist with earlier diagnosis, improve risk stratification, or improve clinical decision making. Current biomarkers for sepsis include lactate, troponin, and procalcitonin. This article discusses the use of lactate, procalcitonin, troponin, and novel biomarkers for use in sepsis.

Best Clinical Practice: Current Controversies in Pulmonary Embolism Imaging and Treatment of Subsegmental Thromboembolic Disease

BACKGROUND Pulmonary embolism (PE) affects >600,000 patients per year in the United States. Evaluation includes clinical decision rules, laboratory tests, and several imaging modalities. The diagnosis of PE has risen in recent years, particularly subsegmental PE (SSPE). Controversy exists concerning the diagnosis and treatment of these lesions. OBJECTIVE We sought to provide emergency physicians with a review of the controversies surrounding PE testing and the diagnosis and treatment of SSPE. DISCUSSION With the rise of computed tomography (CT) testing for PE, diagnosis has increased. Providers often omit risk stratification in favor of D-dimer or imaging, which does not have literature support. The detection of PE has risen by 80%, and this increased testing is associated with several risks, including contrast reaction, nephropathy, and increased radiation. SSPE diagnosis has risen with improved imaging technology, but the literature shows low interobserver agreement with diagnosis of true SSPE. Studies disagree on the clinical significance and dangers of this PE subset. The American College of Chest Physicians 2016 guidelines recommend withholding anticoagulation for SSPE with low risk for recurrent thrombus and no concurrent deep vein thrombosis. Patients at high risk for recurrent venous thromboembolism or with deep vein thrombosis warrant anticoagulation. The provider is ultimately responsible for appropriate evaluation with risk stratification and selective testing. CONCLUSIONS SSPE presents a quandary, because the literature differs in showing harm despite increased diagnosis. American College of Chest Physicians guidelines for the treatment of SSPE take into account the patient, the imaging, and other imaging modalities. Providers should use risk stratification with shared decision-making in the evaluation and treatment of SSPE.

Zika Virus: What Do Emergency Physicians Need to Know?

BACKGROUND Zika virus currently dominates headlines, creating public fear due to its complications. With the ease of worldwide travel, this disease has spread rapidly to the U.S. OBJECTIVES To provide physicians with an updated clinical review of the epidemiology, pathogenesis, diagnosis, management, and mimics of zika virus. DISCUSSION This flavivirus is spread by the bite of the Aedes mosquito during daylight. The ease of worldwide travel has allowed the virus to spread to Mexico and the U.S. Main transmission route is via blood contact or sexual activity involving mucous membranes. Incubation ranges from 2 to 12 days, but only 20% of patients experience symptoms. Fever is low grade with conjunctivitis, arthralgias, myalgias, and a maculopapular rash. Chikungunya and Dengue Fever differ in that patients experience higher fever and no conjunctivitits. The dreaded complication of Zika virus is microcephaly in infants born to infected mothers. Guillain-Barre Syndrome is also linked to the virus. Historical factors including travel history are paramount, and diagnosis includes PCR or serology. No current treatment regimen exists beyond symptom control. The emergency physician must seek to rule out other similar diseases such as malaria, chikungunya, and dengue fever. CONCLUSION Zika virus has created public fear due to complications, and this flavivirus spread by the Aedes mosquito presents similarly to Chikungunya and Dengue Fever. The dreaded complication of Zika virus is microcephaly in infants born to infected mothers. This review provides key information concerning the disease and management.

The emergency management of ventricular assist devices

BACKGROUND Heart failure is a common condition in the United States. When medical therapy fails, ventricular device (LVAD) therapy may be required. With increasing use of LVADs, emergency physicians should understand how to manage problems that may arise with these devices. OBJECTIVE The objective of this review is to familiarize physicians with LVAD components and LVAD physiology, and discuss the evaluation and management of LVAD complications. DISCUSSION The LVAD contains numerous components, but the most important include the pump, inflow and outflow cannulas, and driveline. Initial assessment of perfusion is vital, as hemodynamic instability may be due to decreased preload, increased afterload, mechanical failure, dysrhythmias, infection, or bleeding. Assessment of hemodynamic status is required, and utilization of Doppler for measurement of mean arterial pressure is warranted. This review provides recommendations for the evaluation and management of the LVAD patient in heart failure, the unstable patient with decreased preload, the unstable patient with increased afterload, thrombosis of the LVAD, mechanical failure, dysrhythmias and cardiac arrest, infections and sepsis, right ventricular failure, aortic insufficiency, and bleeding. Patients with LVAD require consultation with the LVAD coordinator and cardiothoracic surgeon. By understanding these aspects, physicians can provide optimal management for these complicated patients. CONCLUSION With an increasing number of LVADs, emergency physicians should expect to see patients with complications directly or indirectly related to LVADs. This review provides physicians with an extensive review of LVAD physiology and the evaluation and management of potential complications related to the device.

Mucormycosis: what emergency physicians need to know?

BACKGROUND Mucormycosis is a rare presentation for patients in the emergency department (ED), primarily affecting immunocompromised patients. Multiple forms of infection are present, and with poor prognosis, ED diagnosis and treatment of this deadly condition are necessary. OBJECTIVE OF REVIEW The aim of this review is to provide an overview of the presentations and forms of mucormycosis, diagnosis, and treatment of this deadly disease. DISCUSSION This review provides background on the fungi causing mucormycosis, which are prevalent in nature. The article discusses the risk factors for infection with mucormycosis, as normal hosts are able to clear the disease, but immunocompromised and diabetic patients are at risk for organism inoculation and spread. The fungi are angioinvasive and cause necrosis. This article describes the various forms of the disease: rhino-orbital-cerebral, pulmonary, central nervous system, gastrointestinal, renal, disseminated, and cutaneous. Finally, this review evaluates diagnosis, treatment, and prognosis. CONCLUSION Emergency department diagnosis and treatment are necessary in patients with infection with mucormycosis. Physicians should be suspicious of this disease in immunocompromised and diabetic patients. Treatment requires antifungal agents such as amphotericin B and surgical debridement. Prognosis is poor.

Clinical ReviewClinical Mimics: An Emergency Medicine–Focused Review of Sepsis Mimics

BACKGROUND Sepsis is a common clinical condition, and mortality and morbidity may be severe. The current definition of sepsis involves systemic inflammatory response syndrome (SIRS) criteria, which is met by many conditions. OBJECTIVE This review evaluates the SIRS continuum, signs and symptoms of sepsis, mimics of sepsis, and an approach to management for sepsis mimics. DISCUSSION The current emergency medicine definition of sepsis includes SIRS, a definition that may be met by many conditions. Because of common pathophysiologic responses, these diseases present in a similar manner. These conditions include anaphylaxis, gastrointestinal emergency, pulmonary disease, metabolic abnormality, toxin ingestion/withdrawal, vasculitis, and spinal injury. Many of these conditions can be deadly if they are not diagnosed and managed. However, differentiating between sepsis and mimics can be difficult in the emergency setting. Laboratory abnormalities in isolation do not provide a definitive diagnosis. However, a combination of history, physical examination, and adjunctive studies may assist providers. For the patient in extremis, resuscitation must take precedence while attempts to differentiate sepsis from mimics are underway. CONCLUSIONS SIRS and sepsis exist along a continuum, with many other conditions overlapping because of a common physiologic response. A combination of factors will assist providers in differentiating sepsis from mimics rather than using diagnostic studies in isolation. Resuscitation should be initiated while attempting to differentiate sepsis from its mimics.

Emergency Medicine Management of Sickle Cell Disease Complications: An Evidence-Based Update

BACKGROUND Sickle cell disease (SCD) affects approximately 100,000 individuals in the United States. Due to alterations in the structural conformation of hemoglobin molecules under deoxygenated conditions, patients with SCD are predisposed to numerous sequelae, many of which require acute intervention. OBJECTIVE Our aim was to provide emergency physicians with an evidence-based update regarding the diagnosis and management of SCD complications. DISCUSSION SCD patients experience significant morbidity and mortality secondary to cerebrovascular accident, acute chest syndrome, acute vaso-occlusive pain crises, SCD-related multi-organ failure, cholecystitis, acute intrahepatic cholestasis, acute sickle hepatic crisis, acute hepatic sequestration, priapism, and renal disease. Emergency physicians must recognize acute manifestations of SCD in order to deliver timely management and determine patient disposition. CONCLUSIONS A comprehensive review of the emergency department management of acute SCD complications is provided. Comprehensive understanding of these aspects of SCD can assist physicians in expediting patient evaluation and treatment, thus decreasing the morbidity and mortality associated with this hemoglobinopathy.

The evaluation and management of urolithiasis in the ED: A review of the literature

Background: Urolithiasis is a common condition in the U.S. Patients frequently present to the emergency department (ED) for care, including analgesia and treatments to facilitate stone passage. Objective: With the new evidence concerning the evaluation and treatment of urolithiasis, this review summarizes current literature regarding the ED management of urolithiasis. Discussion: Urolithiasis occurs primarily through supersaturation of urine and commonly presents with flank pain, hematuria, and nausea/vomiting. History, examination, and assessment with several laboratory tests are cornerstones of evaluation. Urinalysis is not diagnostic, but it may be used in association with other assessments. Risk assessment tools and advanced imaging can assist with diagnosis. Computed tomography (CT) is often considered the gold standard. Newer low‐dose CT imaging may reduce radiation. Recent studies support ultrasound as an alternate diagnostic modality, especially in pediatric and pregnant patients. Nonsteroidal anti‐inflammatory drugs remain first‐line therapy, with opioids or intravenous lidocaine reserved for refractory pain. Tamsulosin can increase passage in larger stones but has not demonstrated benefit in smaller stones. Nifedipine and intravenous fluids are not recommended to facilitate passage. Surgical intervention is based upon stone size, duration, and modifying factors. Patients who are discharged should be advised on dietary changes. Conclusion: Urolithiasis is a common disease increasing in prevalence with the potential for significant morbidity. Focused evaluation with history, examination, and testing is important in diagnosis and management. Understanding the clinical features, risk assessment tools, imaging options, and treatment options can assist emergency physicians in the management of urolithiasis.