Renal Emergencies

Dr Debajyoti M. Roy is a renal physician at Changi General Hospital and he's kindly given us permission to cast his talk on renal emergencies in the ED. A tour de force on balanced solutions, practical management, differences between AKI/CKD & dialysis complications.

Syncope guide 2019

A new guide on our site on Syncope! Often overly investigated and common pitfalls abound.

See our guide section here - https://singem.blogspot.com/p/downloads.html

Link is here for pdf.

Comments and edits of course welcome.

Moral injury, not burnout

Dr Zubin Damania does great parody songs but his rants are equally engaging.
This call to arms denounces the odious habit of blaming people rather than systems/institutions. A different viewpoint indeed but well thought out and has evidence at its core.

Other very good links on this topic:

• St-Emlyns podcast on Med students and moral injury
• WRAP EM on the entire wellness/resilience spectrum
• Dr Ken Milne on his personal journey of burnout

How you perceive these challenges (in the ED setting) depends on your world view however your perspective might be influenced by the following; 

1. Stepping into a non metropolis resource limited setting
2. Being a patient or having a loved one be a patient
3. Talk with an "old timer" ED Doc. If they're still in this challenging environment after decades, they must be doing something right.

Systems inherently lack pathos so our efforts must be channeled into doing what best for patients and peer monitoring/support for ourselves/nurses/students.

As always... fight the power! 

Webucation 5/5/18

Web wisdom this round comes from gurus in EBM, critical care, trauma and even some philosophers on the state of affairs in medical education/administration. Credit as always to the original content providers.

• Breech delivery - info for when you need it!
• High flows you should know - all about BiPap and the new-ish HFNC
• The top 10 trauma papers - compiled by St Emlyn's
• Shrug it off - a novel technique for your subclavian needs
• The tPA drug war without end - controversial because science clashes with dollars
• UTI pearls and pitfalls - you'l be surprised at what you learn about "simple" things

• The trouble with mindfulness - one of the best articles I have read recently relating to error prevention and human behaviour. Well worth a read even if not in a "medical" mood.

Common cold or apocalyptic strain?

Sometimes you can learn something even though its common. So make sure you're educated before you "educate" patients.

Source:
https://www.cdc.gov/flu/about/qa/coldflu.htm

What do you mean the sugar is normal?

Here is a post from one of our EM residents, Dr Andew Ho. 
Its about a rare but not impossible scenario which may get more common in the future. See if you can figure out the problem before clicking on the answer button. 


An uncommon diabetic emergency…

You are on a P2 shift. It has been a busy shift so far with many of your existing patients having gastroenteritis. You pick up a new chart which says “vomiting since last night”. This is a 30 year old male with a past history significant only for Type 2 Diabetes Mellitus on follow up with his private General Practitioner (GP). 
He takes pride in having good diabetic control so far. He has been on metformin, and was recently started on empagliflozin (SGLT-2 inhibitor). He also exercises regularly, and under advice of his GP, started on a ketogenic diet (similar to an Atkin’s diet) 4 days prior.

He now complains of non-bloody, non-bilious vomiting - 10 episodes daily for the past 3 days.  He also developed epigastric pain today. There is no complaint of loose stools or fever. Contact and travel history are unremarkable. He is haemodynamically stable and his abdomen is soft and non-tender to palpation

What are your differential diagnoses?

Diabetic ketoacidosis
Infective gastroenteritis
Acute pancreatitis
Intestinal obstruction
Hepatitis

The patient reveals that he checked his own blood sugar just before calling the ambulance, and it was 8.3. You decided to administer an antiemetic and send off some bloods.

The renal panel shows: U 6.0, K 4.2, Na 133, Bicarbonate 5, Cr 86. The venous gas shows a profound metabolic acidosis with pH 7.10, and BE -20.6. Blood ketones come back at 5.8

What is going on here an what is the pathophysiology?

This is Euglycemic DKA (EuDKA). EuDKA is an uncommon entity that mostly occurs in Type 1 DM, but can also occur in Type 2 DM. A learning point here is that the EuDKA would be completely missed if we just looked at the blood glucose alone or if the patient’s medication list was not available. A delayed diagnosis would lead to delayed treatment, and complications of a worsening acidemia. 

What do we know about the clinical features of this entity?

There are two case series on this rare entity. The larger series (37 cases in 17 patients) in the literature is published by Munro et al (1973)². Peters et al published another series in 2015, featuring 13 cases in 9 patients³.

Symptoms:

-          32% presented with vomiting, 10% with abdominal pain, 9% with thirst (Munro et al)

-          Mean duration of symptoms <2 days (range 6 hours – 8 days, Munro et al)

-          8/37 cases had concomitant infections (Munro et al)

-          Many cases had a history of carbohydrate restriction (eg missed school lunch, poor appetite, dental pain, Munro et al)

Epidemiology:

-          17/17 patients were young, range 10-28 years (Munro et al)

-          11/17 patients were female (Munro et al)

-          5/17 patients experienced recurrence during the study period (Munro et al)

-          16/17 patients were insulin-dependent diabetics (Munro et al)

-          1/17 patient was an undiagnosed diabetic! (Munro et al)

-          7/9 patients had type 1 diabetes, 2/9 with type 2 (Peters et al)

-          9/9 patients were on SGLT-2 inhibitors (Peters et al) – as SGLT-2 is being prescribed more since being released in 2013, we may see more EuDKAs!

-          37/37 cases survived to discharge (Munro et al)

Risk factors:

-          SGLT-2 Inhibitors - Ipragliflozin, Dapagliflozin, Luseogliflozin, Tofogliflozin, Canagliflozin, Empagliflozin. Not sure which are approved in Singapore. Our patient is on Empagliflozin.

-          Carbohydrate restriction – ketogenic diet, poor appetite

-          Increased insulin dosage

-          Alcohol abuse

Treatment^4–6 (expert opinion level of evidence only)

IV fluids with balanced crystalloids (with 5% dextrose) – You add dextrose to drip sooner than you would in DKA

-          IV insulin (to close the anion gap and reverse the metabolic acidosis)

-          Watch potassium while on insulin

-          Treat any underlying precipitants eg infections.

-          Correct predisposing factors: review diet, anti-diabetic meds

Our patient was started on IV insulin 0.5 unit/h, with a dextrose/saline drip. He was given regular anti-emetics. His ketones was on a decreasing trend, and metabolic acidosis resolved. He was taken off his empagliflozin on discharge and converted to subcutaneous insulin injections with metformin.

Clinical take home point?

Suspect EuDKA in patients with risk factors and clinical suspicion. The importance of history taking to uncover a patient’s pre-existing medication list cannot be over-emphasized. Check a urine or serum ketone, especially if a HAGMA is seen.

References

1.        Ireland JT, Thomson WS. Euglycemic diabetic ketoacidosis. Br Med J. 1973;3(5871):107.

2.        Munro JF, Campbell IW, McCuish AC, et al. Euglycaemic diabetic ketoacidosis. Br Med J. 1973;2(5866):578-580.

3.        Peters AL, Buschur EO, Buse JB, et al. Euglycemic diabetic ketoacidosis: A potential complication of treatment with sodium-glucose cotransporter 2 inhibition. Diabetes Care. 2015;38(9):1687-1693. doi:10.2337/dc15-0843.

4.        Rezaie S. Euglycemic DKA: It’s not a Myth. http://rebelem.com/euglycemic-dka-not-myth/. Published 2016. Accessed June 28, 2017.

5.        KAILASH P. Euglycemic DKA Secondary to SGLT2 inhibitors. http://www.emdocs.net/euglycemic-dka-secondary-sglt2-inhibitors/. Published 2017. Accessed June 28, 2017.

6.        Cocchio C. Euglycemic DKA from SGLT2 Inhibitors: Don’t Worry, I Can’t Pronounce Them Either. http://empharmd.blogspot.sg/2016/05/euglycemic-dka-from-sglt2-inhibitors.html. Published 2016. Accessed June 28, 2017.

Webucation 30/6/17

Webucation this month comes from the realms of trauma, cardiology. paeds and tests our "mythos" on cardiac arrest management! All credit to the original content providers.

• Pressing those veins
• Is Amiodarone dead?
• Ultrasound in paediatric trauma
• Egg white for sepsis?
• REACTing to REACT2
• The bamboo flute chest drain technique

• Is "A" really top of the treatment list?

The last link should make you wonder - are you really doing the right thing? LMAs that are inserted by ambulance personnel in the Singapore system are more than adequate. 

So things to focus on include:

• High quality CPR
• Reducing the over-oxygenation
• Using ETCO2 and U/S to guide your resuscitation
• Engaging reperfusion strategies early
• Replacing the tube when pendulum of stability has swung your way.

Dialyse this

John Oliver has done more to demystify fiascos in politics, religion and even medicine than most news organisations.
Here he is giving another insightful expose on American "healthcare".

Webucation 26/4/17

This edition of web wisdom hails from the realms of paeds and adult neurology with a smattering of tox and how to move patients. Credit to the original content creators.

• BMI in ED
• The ED transfer
• The 3 must read articles of 2016
• Paediatric cerebral venous thrombosis/
• Still 4 hrs for that level?
• Kicking against stroke thrombolysis

The last link makes you garner some perspectives. Would you really give snake venom to yourself or your loved ones? Know the whole argument prior to making your mind up.

The placebo effect by Joe Lex

Fascinating talk by the revered Dr Joe Lex; a pre-eminent physician with a vast trove of experience in pre-hospital and in-hospital care. He received a standing ovation at last year's ICEM for his talk on evolution of his EM career and EM itself. This talk is an in depth look into the history, ethics, use and misuse of placebo. 

Well worth a listen for all docs:

Joe Lex - Is nothing ethical?

Infuse > push

We always love a ketamine article here so no surprise we're infusing rather than "pushing" this one. Thanks to Journalwatch for this review.

Low-Dose Ketamine for Pain: IV Push or Slow Infusion? Daniel J. Pallin, MD, MPH Reviewing Motov S et al., Am J Emerg Med 2017 Mar 3; Neuropsychiatric side effects were more common with intravenous push administration, but does it matter?

At intravenous (IV) doses of 0.1–0.3 mg/kg, ketamine is a safe and effective analgesic. Adverse effects are minimal and include sedation and a feeling of disconnection from reality. Investigators compared the effectiveness and adverse effect burden of ketamine administration by IV push versus slow infusion in a randomized, placebo-controlled, double-dummy trial. Forty-eight emergency department patients with acute pain received 0.3 mg/kg of IV ketamine given either over 5 minutes by push or over 15 minutes by infusion. Feelings of unreality (quantified using the Side Effects Rating Scale for Dissociative Anesthetics) were more common in the IV push group overall (92% vs. 54%). Sedation was more pronounced in the IV push group, with median Richmond Agitation-Sedation Scale values at 5 minutes of −2 versus 0. The groups were comparable in terms of analgesic efficacy, but feelings of unreality were more pronounced in the IV push route at all time points. Comment This well-conducted study suggests that analgesic-dose ketamine causes less dissociation and sedation when infused over 15 minutes than when pushed over 5 minutes.

Surviving sepsis 2017

Great update on sepsis by JournalWatch. For those who do not have access:

Surviving Sepsis Campaign Updates Guidelines for Management of Sepsis and Septic Shock Daniel M. Lindberg, MD Reviewing Rhodes A et al., Intensive Care Med 2017 Jan 18; This revision of the 2012 guidelines focuses on early management in adults.

Sponsoring Organizations: Surviving Sepsis Campaign, Society of Critical Care Medicine, and European Society of Intensive Care Medicine Target Population: Clinicians who care for adult patients with sepsis and septic shock in a hospital setting. Background and Objective Sepsis remains incompletely understood, imperfectly defined, underrecognized, and exceptionally lethal. The Surviving Sepsis Campaign convened 55 experts from 25 organizations to undertake a systematic review and grading of evidence to update guidelines for the management of sepsis and septic shock in adult patients (NEJM JW Emerg Med Apr 2013 and Crit Care Med 2013; 41:580). This revision was conducted before publication of the Sepsis-3 definitions and does not incorporate them (NEJM JW Gen Med Mar 15 2016 and JAMA 2016 Feb 23; 315:801). Key Recommendations Patients with hypoperfusion should receive at least 30 mL/kg of IV crystalloid within 3 hours (strong recommendation, low quality of evidence), and should be re-assessed frequently (best practice statement). For patients who require vasopressors, the initial target mean arterial pressure should be 65 mm Hg (strong recommendation, moderate quality of evidence). IV antibiotics should be started within 1 hour of sepsis recognition (strong recommendation, moderate quality of evidence), and should include combination therapy (at least two classes of antibiotics to cover a known or suspected pathogen) for patients with septic shock. Combination therapy should not routinely be used for patients without shock. Norepinephrine is the first choice for patients who need vasopressors. Vasopressin or epinephrine can be added. For patients who remain unstable, dobutamine is recommended. IV hydrocortisone (200 mg/day) is suggested for patients who are hemodynamically unstable despite fluids and vasopressors. Blood transfusion should be reserved for patients with hemoglobin concentration <7.0 g/dL, except in special circumstances such as hemorrhage and myocardial ischemia (strong recommendation, high quality of evidence). Platelets should be given if the platelet count is <10,000/mm3 or <20,000/mm3 with bleeding. Sodium bicarbonate should not be used for most patients with pH ≥7.15. What's Changed With publication of the PROCESS and ARISE trials, these guidelines de-emphasize protocolization of care and invasive monitoring, instead suggesting that patients be re-evaluated frequently. Comment We continue to search for new definitions, diagnostic tests, antimicrobials, and treatments for patients with sepsis. However, improving outcomes probably has as much to do with increasing adherence to the practices we already know are effective and embedding automated passive alerting functions in the electronic medical record. For patients with sepsis, provide early, aggressive treatment with fluids and antibiotics, coupled with frequent re-assessment. CITATION(S): Rhodes A et al. Surviving sepsis campaign: International guidelines for management of sepsis and septic shock: 2016. Intensive Care Med 2017 Jan 18; [e-pub]. (http://dx.doi.org/10.1007/s00134-017-4683-6)

Sounds better?

Terrible solar rotation this planet has had. Good to round off the year with something to remind us of the better angels of our nature. Happy 2017 folks!

The New Antibiotic Mantra—“Shorter Is Better”

This is a post by Dr Ang Shiang Hu.

In line with the drive for "less is more", sometimes, "shorter is better" too.

Infections in which a shorter course of antibiotics has been shown to be equivalent to longer "standard" courses:

Reference here: JAMA Internal Medicine September 2016 Volume 176, Number 9

Webucation 29/5/16

Webucation this month comes from the realms of paedatric surgery, urology and even on some tele-medicine. Remember to visit and credit the original posters.

• No place to be - Not what you'd expect a surgeon to say
• A fontanelle of youth - Battle the Bulge
• Torsion pearls and pitfalls - Its not just the guys, girls get it too.
• Reboa - Rreat talk about a great topic on new use of catheters!
• Calling for help - Phone etiquette for the busy physician
• Metaphysis this! - Vegetables are good for you says Radiopedia

• Sepsis-3 - This is need to know classification for all who deal with this disease

The last link is a must read for those in our speciality. For it is said many a time that the 2 things that we deal with mostly in our career are related to vascular problems and sepsis. So be good at them.

How fluid is your practice?

Here's another talk from SMACC Chicago last year from luminaries in teh critical care field debating some thorny issues.
CAUTION: Some profanity and dogma changing views. Might make you think about what you're doing everyday!
Kudos to the SMACC team and animators for this vid.

SMACC: MacSweeny vs. Marik - On Fluid Responsiveness from Scott from EMCrit on Vimeo.

So does it work?

Here is great article which may change the way you think about drug companies, evidence presentation, fads and the power of distraction. Credit to Prof Joe Lex for tweeting and of course the authors for daring...

BMJ Open 2015;5:e007118 doi:10.1136/bmjopen-2014-007118

• The effect of statins on average survival in randomised trials, an analysis of end point postponement

Abstract

Objective To estimate the average postponement of death in statin trials.

Setting A systematic literature review of all statin trials that presented all-cause survival curves for treated and untreated.

Intervention Statin treatment compared to placebo.

Primary outcome measures The average postponement of death as represented by the area between the survival curves.

Results 6 studies for primary prevention and 5 for secondary prevention with a follow-up between 2.0 and 6.1 years were identified. Death was postponed between −5 and 19 days in primary prevention trials and between −10 and 27 days in secondary prevention trials. The median postponement of death for primary and secondary prevention trials were 3.2 and 4.1 days, respectively.

Conclusions Statin treatment results in a surprisingly small average gain in overall survival within the trials’ running time. For patients whose life expectancy is limited or who have adverse effects of treatment, withholding statin therapy should be considered.

Strengths and limitations of this study

• This is the first study ever to systematically evaluate statin trials using average postponement of death as the primary outcome.
• We have only estimated the survival gain achieved within the trials’ running time, whereas in real life, treatment is often continued much longer.
• We have only focused on all-cause mortality. Other outcomes may also be relevant, for example, non-fatal cardiovascular end points.

Transport is TRICI

The recent SEMS 2016 conference in Singapore was well received by attendees and its myriad of workshops/courses and talks continues to grow. This year, Changi General Hospital added a one day workshop to highlight the troubles in transporting critically ill patients. It involved lectures, simulation, quizzes and demos and lots of food.

"Shoutout" goes to Changi Simulation Institute for once again hosting and moulaging our sims.

TRANSPORT In the Critically Ill 

(aka TRICI)

What its all about - TRICI

Demonstrating practically our retrieval bag and contents

Dr Joanne Ang debriefing after a multi-stage simulation

No gain without pain

The actual quiz - learning without the stress of marks

Dr Charles Chan-Johnson (centre) & SSN Himmah (extreme left) giving a synopsis of actual ambulance transport

Ambulance ride along with mannequin

Teaching faculty of Dr Naleen and SSN Irene "treating" a critical patient

A/Prof Loh Lik Eng giving a paediatric transport primer

Feedback was encouraging and we plan to have more of the above. If you would like to join/participate/know more do send us an email.

Ketamine squared

Here's Prof Larry Mellick giving another stellar reason to use one of our favourite drugs (legally that is) of use in the ED.
As an add-on, also refer to Reuben Strayer's excellent talk from SMACC. 
For more of his videos, go here.

Fencing with snake venom

Lots has been said and lots will be said about tPA in stroke. It matters not which side of the fence you trek so long as you acknowledge that there isaonther side (ie. the fence exists). 

Here is a well put critique of the recent AHA/ASA update. 

It is worthwhile noting that ACEM and ACEP have updated position statements on this subject. Rightly reflecting that clinicians should neither be lulled nor bullied into poor decisions for our patients.

For those who want a concise summary of the opposing view, go to this site. Here's a succinct snapshot for those with less time: