ACMT Toxicology Visual Pearls – Necrotic Spider Bite
A patient bitten by the pictured creature with the pictured lesion should be screened for which pathology?
- Acute liver failure
- Ascending paralysis
- Hemolysis
- Meningitis
- Myocarditis
Geriatric EM: Falls Can Be Sentinel Events
A 72-year-old woman is brought to your Emergency Department (ED) after falling while rushing to the toilet. She has no visible deformity on examination and is discharged with pain medications. Two weeks later, EMS transports her to the ED after a loss of consciousness. Computed tomography (CT) of the head at that time shows a subdural hematoma.
Unfortunately, this scenario is common. Given time constraints in the ED, management plans often miss opportunities to assess a patient’s risk for falling and may not be compliant with recommendations [1, 2]. However, falling can be a sentinel event for older adult patients [3].
Falls can be sentinel events
While emergency physicians may focus on trauma burden or concern for cardiac arrhythmia acutely, falls have a surprisingly high one-year mortality rate at 21.9% [4]. Falling causes up to 12% of deaths in the geriatric population [5]. They can lead to both serious and non-serious complications, for example, fractures and intracranial injury, a decline in health and function, social isolation, increased risk of nursing home admission, and loss of confidence [6-11]. Providers in the ED can begin the process of detecting who is at high-risk for falling in the future to prevent such high morbidity and mortality.
Quick assessment in the ED
Unfortunately, while there are many tools to screen for fall risk, none have been validated in the ED. Below are some tools that can be used as part of a more complete clinical assessment.
The STEADI Algorithm [12, 13] comprises various components, including:
- Screening questions
- Have you fallen in the past year? If so, how many?
- Do you feel unsteady when standing or walking?
- Do you worry about falling?
- Timed Up and Go (TUG) test [12, 14, 15]
- The patient sits in a standard armchair. When the provider says “Go,” the patient stands up from the chair, walks 3 meters (10 feet), turn, and walk back to sit at the chair. The provider records the time.
- Observe the patient for gait/balance instability.
If “Yes” to any question, a TUG ≥12 seconds, or gait or balance instability, the patient may be at risk of fall and further assessment should be considered.
Tiedemann’s Brief Performance-Based Fall Risk assessment tool [16]
- History taking
- Previous fall? (Y/N)
- Medication review
- Four or more (excluding vitamins)? (Y/N)
- Any psychotropic? (Y/N)
- Visual acuity test – Unable to see all of line 16 on a low contrast visual acuity test (Y/N)
- Peripheral sensation test – Unable to feel 2 out of 3 trials (Y/N)
- Balance/Coordinated Stepping/Strength
- Near tandem stand test (balance)- Unable to stand for 10 secs (Y/N)
- Alternate step test (coordinated stepping)- Unable to complete in 10 secs (Y/N)
- Sit to stand test (strength)- Unable to complete in 12 secs (Y/N)
Each “Yes” gets 1 score. We can compare the score(s) with the probability of falling.
| Number of risk factors | Probability of falling |
| 0-1 | 7% |
| 2-3 | 13% |
| 4-5 | 27% |
| 6+ | 49% |
Carpenter’s ED fall risk questions [6]
- Presence of non-healing foot sore?
- Any fall in the past 12 months?
- Inability to cut his/her own toenails?
- Self-reported depression?
If there is more than 1 factor present, the patient is at increased risk for a fall in 6 months. If you are unable to use one of these screening tools, it may be most useful to review high-risk medications and observe them walk.
High-risk medications [17]
- Sedative-hypnotic and anxiolytic drugs (especially long-acting benzodiazepines)
- Tricyclic antidepressants
- Major tranquilizers (phenothiazines and butyrophenones)
- Antihypertensive drugs
- Cardiac medications
- Corticosteroids
- Nonsteroidal anti-inflammatory drugs
- Anticholinergic drugs
- Hypoglycemic agents
- Any medication that is likely to affect balance
Educate the patient
An important consideration is to educate the patient on fall prevention. The American College of Emergency Physicians sponsored the creation of a video, the 7 Step Challenge to Prevent Falls, that you can include in your patient’s discharge summary or have them watch prior to discharge.
Take Home Points
- Falls can be sentinel events and represent a high risk for morbidity and mortality for older adult patients.
- Emergency physicians can play a crucial role in identifying patients at risk and preventing future injury.
References:
- Davenport K, Alazemi M, Sri-On J, Liu S. Missed Opportunities to Diagnose and Intervene in Modifiable Risk Factors for Older Emergency Department Patients Presenting After a Fall. Ann Emerg Med. 2020;76(6):730-738. doi:10.1016/j.annemergmed.2020.06.020. PMID: 33010956
- Tirrell G, Sri‐on J, Lipsitz LA, Camargo CA Jr, Kabrhel C, Liu SW. Evaluation of Older Adult Patients With Falls in the Emergency Department: Discordance With National Guidelines. Academic Emergency Medicine. 2015;22(4):461-467. doi: 10.1111/acem.12634. PMCID: PMC6778963
- Carpenter CR, Cameron A, Ganz DA, Liu S. Older Adult Falls in Emergency Medicine-A Sentinel Event. Clin Geriatr Med. 2018;34(3):355-367. doi:10.1016/j.cger.2018.04.002. PMID: 30031421
- Tan MP, Kamaruzzaman SB, Zakaria MI, Chin A-V, Poi PJH. Ten-year mortality in older patients attending the emergency department after a fall: Ten-year ED fall mortality. Geriatrics & Gerontology International. 2016;16(1):111-117. doi:10.1111/ggi.12446
- Greenhouse AH. Falls among the elderly. In: Clinical Neurology of Aging. 2nd ed. Oxford University Press; 1994:611-626.
- Carpenter CR, Scheatzle MD, D’Antonio JA, Ricci PT, Coben JH. Identification of Fall Risk Factors in Older Adult Emergency Department Patients. Academic Emergency Medicine. 2009;16(3):211-219. doi:10.1111/j.1553-2712.2009.00351.x. PMID: 19281493
- Tinetti ME, Williams CS. Falls, Injuries Due to Falls, and the Risk of Admission to a Nursing Home. N Engl J Med. 1997;337(18):1279-1284. doi:10.1056/NEJM199710303371806. PMID: 9345078
- Boele van Hensbroek P, van Dijk N, van Breda GF, et al. The CAREFALL Triage instrument identifying risk factors for recurrent falls in elderly patients. The American Journal of Emergency Medicine. 2009;27(1):23-36. doi:10.1016/j.ajem.2008.01.029. PMID: 19041530
- Tromp AM, Pluijm SMF, Smit JH, Deeg DJH, Bouter LM, Lips P. Fall-risk screening test. Journal of Clinical Epidemiology. 2001;54(8):837-844. doi:10.1016/S0895-4356(01)00349-3. PMID: 11470394
- Bergen G, Stevens MR, Burns ER. Falls and Fall Injuries Among Adults Aged ≥65 Years — United States, 2014. MMWR Morb Mortal Wkly Rep. 2016;65:993–998. doi:10.15585/mmwr.mm6537a2. PMID: 27656914
- Gill TM, Murphy TE, Gahbauer EA, Allore HG. The Course of Disability Before and After a Serious Fall Injury. JAMA Intern Med. 2013;173(19):1780. doi:10.1001/jamainternmed.2013.9063. PMCID: PMC3812391
- Stevens JA, Phelan EA. Development of STEADI: A Fall Prevention Resource for Health Care Providers. Health Promotion Practice. 2013;14(5):706-714. doi:10.1177/1524839912463576. PMCID: PMC4707651
- Centers for Disease Control and Prevention. STEADI Algorithm for Fall Risk Screening, Assessment, and Intervention among Community-Dwelling Adults 65 years and older. Published online 2019. Accessed November 20, 2020. https://www.cdc.gov/steadi/pdf/STEADI-Algorithm-508.pdf
- Podsiadlo D, Richardson S. The Timed “Up & Go”: A Test of Basic Functional Mobility for Frail Elderly Persons. Journal of the American Geriatrics Society. 1991 Feb;39(2):142–8. doi: 10.1111/j.1532-5415.1991.tb01616.x. PMID: 1991946
- Barry E, Galvin R, Keogh C, Horgan F, Fahey T. Is the Timed Up and Go test a useful predictor of risk of fall in community dwelling older adults: a systematic review and meta-analysis. BMC Geriatr. 2014;14:14. doi:10.1186/1471-2318-14-14. PMCID: PMC3924230
- Tiedemann A, Lord SR, Sherrington C. The Development and Validation of a Brief Performance-Based Fall Risk Assessment Tool for Use in Primary Care. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences. 2010;65A(8):896-903. doi:10.1093/gerona/glq067. PMID: 20522529
- Fuller GF. Falls in the elderly. Am Fam Physician. 2000;61(7):2159-2168, 2173-2174. PMID: 10779256
IDEA Series: Handheld Ultrasound for Emergency Medicine Residents Rotating on Cardiology Services
Point-of-care ultrasound (PoCUS) has become an essential skill that emergency medicine (EM) residents learn during their training [1]. Accordingly, most EM programs schedule a block early in residency dedicated to obtaining and interpreting high-quality PoCUS images. Likewise, the ability to efficiently diagnose and manage acute cardiovascular pathologies is a critical aspect of EM, and most EM residents also rotate on a cardiology service to develop these skills. Despite evidence that PoCUS improves the ability of both cardiologists and non-cardiologists to quickly diagnose cardiac disease at the bedside, integration of this relatively novel technology on cardiology services is often limited by lack of PoCUS availability as well as lack of a convenient platform to share recorded images [2]. Equipping EM residents on cardiology rotations with a portable, handheld ultrasound (US) system (Figure 1. Philips Lumify handheld US system with tablet) can enhance the learning of echocardiography acquisition and interpretation while simultaneously providing cardiology teams with clinically actionable information [3]. In addition to improving patient care, performing and interpreting PoCUS from the lens of a cardiologist is a simple yet innovative way to solidify the skills that are crucial to becoming an excellent bedside echocardiographer.
SplintER Series: A Stressful Step – Midfoot Pain in a Female Runner
A 17 year-old female who recently started training for a marathon presents with progressively severe pain over her midfoot, notable for point tenderness over the 2nd metatarsal shaft. The above image was obtained (Image 1. X-ray of the left foot. Image courtesy of Matthew Negaard, MD). (more…)
SAEM Clinical Image Series: Edema Got Your Tongue?
A 57-year-old male presented to the emergency department with a swollen mouth for three hours. He reported never having experienced this before and denied starting any new medications. The patient endorsed a feeling that his mouth was swollen and had difficulty swallowing. The edema had been increasing in size since its onset. He had been drooling for the past hour and endorsed mild pain around the area. He denied any shortness of breath, rash, nausea, vomiting, or other areas of edema. His past medical history included hypertension, diabetes, and allergies, with no known drug allergies. His family history was unknown. His medications included Metformin and Lisinopril.
SAEM Clinical Image Series: Sun-burnt Hands and Lips
A 44-year-old Caucasian male with a past medical history of hepatitis C presents with a complaint of pain, swelling, and skin blistering of his hands. He also notes skin sores on his nose, lower lip, and the tops of his ears. The patient claims that these have become progressively worse since starting work a month ago in outdoor construction. The patient denies the use of medications or illicit drugs and denies any medical allergies. He admits to tobacco use and daily alcohol use. The patient denies any other symptoms.
Colchicine Toxicity: A New Threat from COVID-19 Treatments
In the continued fight against COVID-19, a January 22, 2021 press release from the Montreal Heart Institute touted the potential of colchicine, citing results from the COLCORONA trial [1, 2]. We’ve learned to be especially skeptical of any study results reported only via press release before undergoing full peer-review and publication. Nevertheless, the authors claim a non-significant (p=0.08) relative risk reduction of 19% (absolute risk reduction 1.1%) in hospitalizations, mechanical ventilation, and death. Note that the pre-print of the study has still not been peer-reviewed [3]. This study comes on the heels of the much smaller GRECCO-19 study published in June 2020 [4].
Early in 2020, promising results on hydroxychloroquine for treatment of COVID-19 led to a large increase in its use in outpatients and inpatients. It is now known that there is virtually no role for hydroxychloroquine and that this spike in use led to serious toxicity both from therapeutic use and overdose [5, 6]. The same may be anticipated for colchicine. And, if there is a drug that toxicologists fear more than hydroxychloroquine in overdose, it’s colchicine.
5 things to know about colchicine toxicity
1. Colchicine inhibits microtubule formation and function, thereby inhibiting mitosis.
- It also is a GABA-A antagonist.
2. Acute toxicity occurs in 3 phases.
- 0-24 hours: Nausea, vomiting, diarrhea, salt and water depletion, and leukocytosis
- 1-7 days: Sudden cardiac death (24-48 hours), pancytopenia, acute kidney injury, sepsis, acute respiratory distress syndrome, rhabdomyolysis, and electrolyte imbalance
- >7 days: Alopecia, myopathy, neuropathy, and myoneuropathy
3. Colchicine levels are not helpful.
- They also aren’t readily available at most institutions.
4. Hemodialysis doesn’t remove the toxin.
- Colchicine’s volume of distribution is large.
- Extracorporeal treatment can be employed if kidney toxicity results from the poisoning.
5. There is no antidote.
- Management is largely supportive with IV fluids, vasopressors, and colony-stimulating factors.
- Experimental anti-colchicine Fab fragments are being studied [7].
This 2010 Clinical Toxicology review article provides further information and education on colchicine toxicity.
Want to learn more about EM Pharmacology?
Read other articles in the EM Pharm Pearls Series.
References:
- Montreal Heart Institute. Colchicine reduces the risk of COVID-19-related complications. GlobalNewswire website. January 22, 2021. Accessed January 26, 2021.
- Montretal Heart Institute. ColCorona. Accessed January 26, 2021.
- Tardif J-C, Bouabdallaoui N, L’Allier PL, et al. Efficacy of colchicine in non-hospitalized patients with covid-19. medRxiv. doi: Epub 2021 Jan 27.
- Deftereos SG, Giannopoulos G, Vrachatis DA, et al. Effect of colchicine vs standard care on cardiac and inflammatory biomarkers and clinical outcomes in patients hospitalized with coronavirus disease 2019: the grecco-19 randomized clinical trial. JAMA Netw Open. 2020;3(6):e2013136. doi: 10.1001/jamanetworkopen.2020.13136. PMID: 32579195.
- Mahan KM, Hayes BD, North CM, et al. Utility of hypertonic saline and diazepam in covid-19–related hydroxychloroquine toxicity. The Journal of Emergency Medicine. doi: 10.1016/j.jemermed.2020.10.048. Epub 2020 Oct 2020. PMID: 33353811.
- Chai PR, Ferro EG, Kirshenbaum JM, et al. Intentional hydroxychloroquine overdose treated with high-dose diazepam: an increasing concern in the covid-19 pandemic. J Med Toxicol. 2020;16(3):314-320. doi: 10.1007/s13181-020-00790-8. PMID: 32514696.
- Eddleston M, Fabresse N, Thompson A, et al. Anti-colchicine Fab fragments prevent lethal colchicine toxicity in a porcine model: a pharmacokinetic and clinical study. Clinical Toxicology. 2018;56(8):773-781. doi: 10.1080/15563650.2017.1422510. PMID: 29334816.