Corticosteroid Use in Acute Herpes Zoster Infection (Shingles)

Clinical EM Bottom Line:

  • Corticosteroids do not prevent postherpatic neuralgia in herpes zoster infection (Shingles).
  • Corticosteroids may decrease the duration of pain in the acute phase of Shingles when given as a 3 week tapered course.

Reference:

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SJRMC Conference – Paterson, NJ [February 26, 2014]

Tintinalli Quiz Pearls - Dr. John Kashani

  • Organophosphates
    • Both Atropine and Pralidoxime are used for significant poisoning
    • The dose of Atropine is titrated until copious bronchial secretions attenuate
    • Atropine should not be withheld in the setting of tachycardia
    • If given early, Pralidoxime may reverse muscle paralysis
  • Lindane – Causes seizures via inhibition of GABA-mediated inhibition of the CNS
  • Paraquat – Causes lung injury by forming a superoxide radical in alveolar cells
  • Benadryl – Most common cause of anticholinergic toxicity
  • Physostigmine
    • Reversible Acetylcholinesterase inhibitor
    • May be considered in cases of severe agitation secondary to anticholinergic toxicity
    • In the case of an undifferentiated poisoning, a diagnostic challenge with Physostigmine is not recommended
    • The use of Physostigmine to reverse anticholinergic toxicity remains controversial
  • Lead
    • Most common cause of chronic metal poisoning
    • Elevated levels in children 1-5yo has been linked to urban dwellings, higher population density and dwellings before 1974
    • Children are most commonly exposed to lead through lead-based paint
    • Greater than 90% of total body lead is stored in the bone
  • Arsine – Exposure can potentially cause acute hemolytic anemia
  • Management of ingestion of contents of mercury thermometer – Reassurance and Discharge

Management of the Pregnant Trauma Patient – Dr. Blessit George-Varghese

  • Avoid BMV if not completely necessary, consider early NGT placement to decompress
  • Place chest tube 2-3 spaces higher midaxillary line
  • Be aggressive in volume resuscitation (remember fetus requires 20% of maternal circulatory volume). Pregnant women crash late and fast.
  • Compare Hgb/Hct to old lab values if possible, borderline Cr is a sign of renal injury
  • Consider tachycardia and hypotension as signs of instability until proven otherwise
  • Peripheral and central IV access should always be placed above the diaphragm
  • No Amiodarone in cardiac arrest
  • Perimortem c-section should occur within 4 minutes of loss of pulses (guidelines recommend)
  • Give Rhogam to the Rh (-) female
  • Secondary survey includes vaginal exam and fetal monitoring
  • Send a KB test for third trimester bleeding
  • Do not forego any necessary imaging
  • Placental abruption – cause of persistent hypotension. Do fetal CTM

Catatonia in the Emergency Department – Dr. Brian Yokers

  • Catatonia is a condition marked by changes in muscle tone or activity and abnormal behavior associated with a large number of serious mental and physical illnesses.
  • Failure to consider catatonia in the Ddx:
    • Potentially creates delays in diagnosis
    • Excessive testing
    • Increased hospital length of stay
    • Increased morbidity and mortality.
  • Failure to consider a broad Ddx in the catatonic patient: Catatonia is associated with a multitude of mental and physical illnesses and may require significant workup in the ED.
  • If you suspect catatonia, consider giving a test dose of Lorazepam (1-2mg IV).  This may improve symptoms and may allow for more clarity in identifying any underlying illnesses.  Electroconvulsive therapy is indicated in refractory cases.
  • Lethal Catatonia is autonomic instability in the catatonic patient.  NMS and serotonin syndrome are related syndromes secondary to drug administration (antipsychotics and serotonergic drugs respectively) and treatment is primarily Benzodiazepines and supportive therapy.

Anaphylaxis and Angioedema Pearls – Dr. Wael Azer (@waelazerwael)

Anaphylaxis

  • Initial Assessment of Anaphylaxis:
    • Rapidly evaluate the patient’s Airway, Breathing and Circulation
    • Assessment Triangle: ABC
      • Appearance- overall appearance
      • Work of Breathing
      • Color- skin color- hypoxia?  Pallor?
  • Physical Exam Pearl: If patient can vocalize a high pitched “EEEE” then airway swelling is unlikely
  • Diagnostic Criteria for Anaphylaxis:
    • Combination of skin findings (rash, itching, hives) with:
      • Low Blood Pressure
      • Respiratory Compromise (Stridor, Dyspnea, Wheezing)
      • Persistent GI symptoms (Abdominal pain, N/V)
  • Treatment:
    • Mild Allergic Reactions (Skin findings only, Stable vital signs, Does not meet criteria for Anaphylaxis):
      • Antihistamines: Benadryl (Diphenhydramine) – 25-50 mg IV, can also give same dose PO if very mild reaction, 1 mg/kg IV for children
      • H2 Blockers: Zantac (Rantidine) 50mg IV or Pepcid (Famotidine) 20mg IV
      • Steroids: Takes 4-6 hours to work, Predisone 50mg PO (1 mg/kg peds), Solumedrol 125mg IV (1 mg/kg IV)
    • Anaphylaxis
      • EPI ,EPI ,EPI
      • EpiPen:  0.3mg EpiPen IM for adults, 0.15mg EpiPen Junior IM for peds
      • Patient on Beta Blockers - Inhibit action of Epi, need to give Glucagon to counteract
        • Glucagon: 1-5mg IV given slowly over 5 mintues, frequently causes vomiting, give with Zofran (Ondansetron)
      • Patient given Epinephrine should be observed for at least 4-6 hours in the ED to make sure patient does not have rebound reaction, low threshold to admit
      • Must discharge patient with Epi Pens: Prescribe at least 2 Epi-Pens (One for patient to carry with them at all times, One for home/school)

Hereditary Angioedema (HAE)

  • Consists of three subtypes:
    • Type I: Low levels of C1-INH and accounts for 80%-85% of cases
    • Type II: Normal levels and decreased function of C1-INH and accounts for most of the remaining 15%-20% of cases
    • TypeIII: Normal levels and normal function of C1-INH has been described, primarily in women ,Type III HAE is thought to be estrogen induced
  • Physical signs of HAE include overt, noninflammatory swelling of the skin and mucous membranes. Typical involvement includes the face, hands, arms, legs, genitalia, and buttocksAbdominal attacks can lead to unnecessary surgery and delay in diagnosis, as well as narcotic dependence due to severe pain
  • The goals of pharmacotherapy for HAE are to reduce morbidity and to prevent complications. Medication may be used for acute or preventive treatment.
  • Choices for treatment, C1-Inhibitor Concentrates :
    • C1-inhibitor – Human (Cinryze) and (Berinert)
    • Kallikrein Inhibitor - Ecallantide (Kalbitor)
    • Bradykinin Receptor Antagonists - Icatibant (Firazyr)

Management of Asthma in the Emergency Department – Dr. Marisa Glashow

  • Nebulizers are less efficient than Metered Dose Inhalers at delivering medication. If the patient is able to tolerate MDIs then this should be considered.  Studies have shown MDI usage in the ED resulted in lower total albuterol dose needed for same effect.
  • The choice to give an asthmatic oral or IV steroids should be based on whether they are vomiting, have AMS, or require IV access for another indication.  There is no difference in clinical improvement based on the route of administration.
  • Magnesium has been shown to be effective only in patients with severe acute asthma.  There has been no recent literature supporting its use in the mild or moderate asthmatic.
  • Ketamine can be given as a bolus 1 mg/kg or as a drip at 0.5-1.0 mg/kg.  This is an excellent choice when sedating an asthmatic.  It is also safe in pregnancy.
  • When choosing a parenteral agent for use during pregnancy, do not use Epinephrine because it causes vasoconstriction of uteralplacental circulation and it crosses the placenta causing fetal tachycardia.  An excellent alternative is Terbutaline.

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