Episode 77 – Alcohol Withdrawal

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Over at the Pulmcrit blog, Dr. Josh Farkas has proposed the use of phenobarbital monotherapy for the treatment of ethanol withdrawal. He argues that phenobarbital has the following advantages:

  • Superior neurochemistry
  • Reliable – some patients will be resistant to benzos but this does not happen as much with phenobarbital
  • Predictable pharmacokinetics

Core Content

We cover alcohol withdrawal using Rosen’s Emergency Medicine (9th ed) Chapter 142 , Tintinalli’s Emergency Medicine (8th ed) Chapter 292, and Goldfrank’s Toxicologic Emergencies (10th ed) Chapter 81  as guides.

 

 

Rosh Review Emergency Board Review Questions

A 49-year-old man presents to the Emergency Department complaining of sweating and tremors. The patient drinks a bottle of liquor per day and stopped suddenly because of a pending court case. His last alcoholic drink was 3 days ago. On physical examination, his blood pressure is 168/105 mm Hg, pulse rate is 106/minute, respirations are 22/minute, and temperature is 99.3°F. The patient appears agitated and restless with a visible tremor of bilateral hands. The triage team ordered folic acid, thiamine, and a multivitamin. Which of the following is the most appropriate disposition?

A. Admit the patient and start diazepam

B.Admit the patient and start disulfiram

C.Discharge the patient with a prescription for diazepam

D.Discharge the patient with a prescription for disulfiram

Answer
A. Admit the patient and start diazepam is the correct disposition because this patient is suffering from alcohol withdrawal, which potentially can be fatal. Withdrawal symptoms occur when a patient has alcohol use disorder and has developed a tolerance to alcohol, where an increased amount of alcohol is needed to achieve the desired effect. When tolerance has developed, cessation leads to withdrawal. Early symptoms of alcohol withdrawal include anxiety, irritability, headache, tremor, tachycardia, hypertension, hyperthermia, and hyperactive reflexes. Seizures (usually grand mal) can develop between 12-24 hours after withdrawal starts. After 24-72 hours, life-threatening delirium tremens may occur, which manifests with signs of altered mental status, hallucinations and marked autonomic instability. Treatment of alcohol withdrawal involves giving a benzodiazepine (e.g. diazepam) until symptoms lessen and then tapering the dosage over days to weeks. Thiamine, folic acid, and vitamin B12 are also administered and any electrolyte abnormalities are corrected (typically low potassium and magnesium). Following withdrawal, the patient should be referred to support groups. Long term medication used to deter use of alcohol include naltrexone, disulfiram, and acamprosate.

Admit the patient and start disulfiram (A) is incorrect because the patient needs a benzodiazepine medication to prevent delirium tremens and potentially fatal consequences. Disulfiram is a medication used in some patients for long-term adherence to alcohol abstinence. Ingestion of alcohol while taking disulfiram causes copious vomiting and potentially more severe reactions. Discharge the patient with a prescription for diazepam (C) or disulfiram (D) is incorrect because alcohol withdrawal is potentially lethal and this patient should be admitted.

References:

  1. “Alcohol Related Diseases.” Rosen’s Emergency Medicine. 9th ed. Chapter 142, 1838-1851.e1
  2. “Substance Use Disorders.” Tintinalli’s Emergency Medicine: A Comprehensive Review. 9th ed. Chapter 281.
  3. “Ethanol Withdrawal.” Goldfrank’s Toxicologic Emergencies. 10th ed. Chapter 81.
  4. Hendey GW, Dery RA, Barnes RL, Snowden B, Mentler P. A prospective, randomized, trial of phenobarbital versus benzodiazepines for acute alcohol withdrawal. Am J Emerg Med. 2011;29(4):382-385.
  5. Young GP, Rores C, Murphy C, Dailey RH. Intravenous phenobarbital for alcohol withdrawal and convulsions. Ann Emerg Med. 1987;16(8):847-850.

Episode 76 – Pneumoperitoneum, Gastritis, & PUD

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5MinSono has a great 5 minute videocast on the ultrasound diagnosis of pneumoperitoneum.

Core Content

We cover gastropathies and peptic ulcer disease (PUD) using Rosen’s Emergency Medicine (9th ed) Chapter 79 and Tintinalli’s Emergency Medicine (8th ed) Chapter 78  as guides.

Rosh Review Emergency Board Review Questions

A 67-year old man with chronic osteoarthritis complains of gnawing and burning in the epigastric area that is occasionally accompanied by nausea and vomiting. His current BMI is 26 and he is physically active. What is the most probable cause for these symptoms?

A. Cholelithiasis

B. Gastric carcinoma

C. Nonsteroidal anti-inflammatory drug induced gastritis

D. Peptic ulcer disease

Answer
C. Nonsteroidal anti-inflammatory drug (NSAID) therapy is the first line treatment in osteoarthritis, however chronic NSAID use can often destroy the gastric mucosa leading to hemorrhage, erosions and ulcers. NSAIDs such as naproxen and ibuprofen are the most common agents associated with acute erosive gastritis. A long-term prospective study found that patients with arthritis who were older than 65 years and regularly took low-dose aspirin were at increased risk for dyspepsia severe enough to necessitate the discontinuation of NSAIDs. This suggests that better management of NSAID use should be discussed with older patients in order to reduce NSAID-associated upper GI events. COX -2 inhibitors, such as celecoxib, are an alternate therapy to NSAIDs. Other common agents that cause gastritis include alcohol and Helicobacter pylori. The mainstay treatment of erosive gastritis is to refrain from the offending agent. The gold standard for diagnoses of gastritis is an upper GI endoscopy.

Symptomatic cholelithiasis (A) is often seen in populations who have risk factors for gallstones, which include persons with diabetes mellitus, persons who are obese, women, rapid weight cyclers, and patients on hormone therapy or taking oral contraceptives. This patient does not portray the colicy pain associated with gallstones. Patients with gastric cancer (B) often present with weight loss, dysphagia, postprandial fullness and loss of appetite. Gastric cancer is multifactorial involving both inherited predisposition and environmental factors. Environmental factors implicated in he development of gastric cancer include diet, Helicobacter pylori, previous gastric surgery, pernicious anemia, chronic atrophic gastritis and radiation exposure. Smoking and smoked meats also have a high correlation with gastric cancer. Peptic ulcer disease (D) is a complication of chronic gastritis and can present in a similar manner as gastritis. Peptic ulcers include both gastric and duodenal ulcers. Peptic ulcers present with gnawing or burning sensation that occur after meals. Common risk factors include H. pylori infection and ingestion of NSAIDs. An upper GI endoscopy must be performed to visualize the ulcers. Biopsy is indicated if ulcers are seen on endoscopy in order to rule out Helicobacter pylori. Active ulcers associated with NSAID use are treated with an appropriate course of proton pump inhibitor (PPI) therapy and the cessation of NSAIDs. For patients with a known history of ulcer and in whom NSAID use is unavoidable, the lowest possible dose and duration of NSAID and co-therapy with a PPI is recommended.

A 55-year-old man presents with severe abdominal pain and tenderness on examination that began acutely approximately 12 hours prior to arrival. His X-ray is shown below. What is the most appropriate next step?

A. Computed tomography scan of the abdomen and pelvis

B. Nasogastric tube insertion

C. Observation and serial abdominal exams

D. Surgical consultation

Answer

D. The X-ray demonstrates free air under the diaphragm representing a perforated viscus within the intraabdominal cavity. The presence of free air is an indication for an emergent surgical consultation for repair. The emergency provider should administer broad-spectrum antibiotics covering aerobic and anaerobic organisms along with intravenous fluid resuscitation.  

A CT scan of the abdomen and pelvis (A) is indicated if the X-ray does not reveal evidence of free air and the patient has ongoing pain and tenderness requiring a diagnosis. Some perforations will not show on plain films, and as time progresses, the area of perforation may wall off and not show on X-ray. A nasogastric tube (B) is not indicated in the management of a patient with a perforated viscus. Observation and serial abdominal exams (C) are not sufficient for a patient with a perforation.  

A patient presents with hematemesis. What test is most likely to determine the etiology of the bleeding?

A. CT scan of the abdomen and pelvis

B. Nasogastric tube lavage

C. Right upper quadrant ultrasound

D. Upper endoscopy

Answer

Upper endoscopy is the modality that is most likely to identify the culprit lesion in a patient with upper gastrointestinal bleeding (UGIB). UGIB is a common presentation caused by a variety of pathologies including gastritis, esophageal varices, peptic ulcer disease, Mallory-Weiss tears, arteriovenous malformations and Boerhaave’s syndrome. Of these causes, peptic ulcer disease is the most common. Regardless of the etiology, endoscopy represents the best modality for diagnosis. It allows direct visualization of the esophagus, stomach and first two sections of the duodenum. Additionally, it allows for interventions to be performed if active bleeding or stigmata of recent bleeding are found.

CT scan of the abdomen and pelvis (A) is limited in its ability to give a diagnosis. Nasogastric tube lavage (B) may show the presence of blood in the upper GI tract but cannot differentiate between causes. Right upper quadrant ultrasound (C) may give information about the patient including the presence of cirrhosis but cannot give a specific diagnosis as the cause.

References

  1. Nazerian P, Tozzetti C, Vanni S. Accuracy of abdominal ultrasound for the diagnosis of pneumoperitoneum in patients with acute abdominal pain: a pilot study. Critical ultrasound journal. 7(1):15. 2015. [pubmed]

Episode 75 – Mass Casualty Incidents

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We cover Free Open Access Medical Education (FOAM) on mass casualty incidents, an unfortunate reality in the current United States climate (and elsewhere).  There is a must read (truly, emergency providers really should read this) in EP Monthly by Dr.Kevin Menes, How One Las Vegas ED Saved Hundreds of Lives After the Worst Mass Shooting in U.S. History”. He details his process in running the Emergency Department that evening. Some of our favorite pearls

  • Plan ahead and rehearse. This means both mass casualty drills and mental rehearsal. We do this with many things in emergency medicine (thinking about how we would handle rare and critical procedures or disease processes.
  • Prepare once you have the heads up to help mitigate system induced bottlenecks.  When a mass casualty incident is expected, call for help. This means, extra staff to transport patients and techs and nurses. This also may mean calling in all trauma surgeons, anesthesiologists, and emergency providers. Additionally, bring all stretchers and wheelchairs to the ambulance bay. Consider calling for items in bulk. For example, all vials of paralytic, all chest tube trays from central supply, or large quantities of blood products.
  • Triage – according to the textbook the most senior person should be doing this. In Vegas, Dr.Menes discusses how he was needed in the and turned triage over to a senior nurse who had been assisting him in the process to that point.

We cover pearls from other great resources include a post on the St. Emlyn’s blog, “Mass Casualty Incidents: Lessons from the AAST” and a free EBMedicine article on ballistic injuries.

We cover core content on triage and ED treatment pearls using Rosen’s Emergency Medicine Chapter 192 and Tintinalli Chapter 5 as guides

 

Rosh Review Emergency Board Review Questions

A massive explosion occurred at a nearby automotive plant injuring hundreds of employees. You are called to help as part of the disaster team. You are assigned to work on scene triaging patients according to the Simple Triage and Rapid Treatment (START) protocol. Your first victim is found unconscious with significant head and facial trauma. The patient has no spontaneous respirations. What is the most appropriate next step?

A, Assign the patient a black tag

B. Intubate the patient with an endotracheal tube

C. Oxygenate the patient with a bag-valve mask

D. Reposition the patient’s airway

Answer

You should reposition the patient’s airway. In mass casualty situations, emergency personnel often use the Simple Triage and Rapid Treatment (START) technique that allows for rapid assessment of patient’s respirations, perfusion and mental status (RPM). Anyone that is able to walk is asked to move away from the incident site and is assigned a green tag (walking wounded). At this point emergency personnel then quickly assesses the remaining patient’s respirations, pulse and mental status, in order to assign red (immediate), yellow (delayed) or black (deceased) tags. The first step is to assess the patient’s respirations. If they have no spontaneous respirations, you make one attempt to reposition the airway. If there is no improvement, they are assigned a black tag. If they are breathing greater then 30 breaths/minute, they are assigned a red tag. If respirations are less than 30 breaths/minute, then you assess the patient’s perfusion. If their radial pulse is absent or their capillary refill is over 2 seconds, they are given a red tag. If the have a radial pulse or capillary refill less than 2 seconds, you assess their mental status. If they are able to follow commands they are assigned a yellow tag. If they cannot follow commands, they are assigned a red tag.