A patient presents to the ED for management of a spider bite. Which of the following statements is correct regarding a bite from the spider pictured?
Intracranial hemorrhage (ICH) is associated with significant disability and mortality. Although evidence-based guidelines exist, many hospitals have their own institutional practice patterns, which can make it difficult to care for these patients in the ED. Dr. Debbie Yi Madhok, an emergency physician and neurointensivist, sat down with Dr. Derek Monette, the ALiEM Deputy Editor in Chief, to discuss updates in the management of ICH. This interview follows up her original popular 2017 ALiEM post on dilemmas in ICH management, and takes a deeper dive into the nuances of seizure prophylaxis, blood pressure control, and platelet transfusions. We present the podcast and key learning points.
(more…)
The Toxicologist Mindset series features real-life cases from the San Francisco Division of the California Poison Control System.
Case: A previously healthy 49-year-old woman presented to the emergency department (ED) with acute onset of confusion. Family members noticed her to have unsteady gait and she complained of blurry vision and difficulty urinating. She denied the use of any drugs or alcohol and took no medications. In the ED, her vital signs were: T 98.7, BP 95/59, P 130, RR 16, and O2 sat 100% on room air. Her pupils were 7 mm and reactive and her skin was dry. Bowel sounds were present. She had no focal neurological findings, but appeared “very confused” and “frightened.”
Serum electrolytes, CBC, and liver function tests were all unremarkable. She had a negative urine drug screen and alcohol level. The ECG demonstrated sinus tachycardia with normal intervals, and the brain CT was normal.
What are your next thought processes?
Exceptional communication is essential when providing care to patients in the ED. This is especially true given that we don’t have a preexisting relationship with our patients. They have never seen us before, have little or no information about us, and didn’t choose us. They are typically anxious, uncomfortable, and would probably rather be somewhere else. Exceptional communication allows patients to gain trust in us, in our skills, and in our recommendations. Strong communication skills not only allow physician and non-physician staff to gather relevant information and share important findings, but also help improve healthcare outcomes, reduce misunderstandings, and minimize litigation. Below are 10 pearls, divided into 4 habits, to help you get the most out of the clinical encounter and improve your patient’s care experience.
(more…)
Child abuse is a common cause of pediatric morbidity and mortality. In 2015, over 650,000 children were found to be victims of maltreatment and over 1,500 child deaths occurred due to child abuse or neglect in the United States.1 Children under 1 year of age are at the highest risk of abuse with potential for lifelong sequelae. Emergency department providers are in a unique position to recognize child abuse and take appropriate steps to reduce further injury to children. An understanding of the motor development of young children can aid physicians in the identification of clinical red flags in the history.
(more…)
A middle-aged man with a history of diabetes and hypertension presents with nausea, vomiting, and shortness of breath. His laboratory testing is remarkable for a leukocytosis, ketonemia, and an anion gap acidosis (pH of 7.13). The EM resident caring for this patient is surprised to find that the blood glucose is 121 mg/dL.
Which home medication is likely responsible for this presentation?
The patient’s presentation is consistent with diabetic ketoacidosis (DKA) in the absence of hyperglycemia. This entity is known at euglycemic DKA and it is increasingly recognized for an association with a newer oral diabetic medication class, SGLT2 inhibitors. Examples include:
The FDA has approved these three SGLT2 inhibitors for Type 2 diabetics, and at times, they are prescribed off-label for Type 1. The mechanism involves decreasing glucose reabsorption in the nephron’s proximal tubule (via inhibition of the sodium-glucose linked cotransporter-2 protein). This results in increased urinary excretion of glucose that is independent of the body’s insulin secretion.1
Other potential benefits of this class of medications include:1–3
In 2015 the FDA issued a warning, however, that SGLT2 inhibitors may cause ketoacidosis, urinary tract infections, and urosepsis.4 Since then, multiple case reports have been published showing an association between SGLT2 inhibitors and the development of euglycemic DKA.
Euglycemic DKA is an uncommon and likely under-diagnosed phenomenon, best defined as DKA with a lower than expected blood glucose (less than 250 mg/dL according to the American Diabetes Association).4–6
Potential precipitants, in addition to SGLT2 inhibitors, include:7
EPs may delay diagnosis, given the modest glucose levels at the time of presentation. This, however, is false reassurance because DKA is not defined by an absolute blood glucose. Interestingly, patients with euglycemic DKA may have a normal mental status despite marked ketoacidosis, and vomiting seems to be a common complaint.5
Euglycemic DKA treatment is the same as traditional DKA, and includes hydration, insulin, and supportive care. Patients with euglycemic DKA may also need a dextrose infusion given the lower glucose levels.
The mechanisms by which SGLT2 inhibitors cause or predispose to euglycemic DKA are unclear and likely complex. SGLT2 inhibitors may lead to a decrease in either endogenous or exogenous insulin, and an increase in glucagon production.8 This insulin deficiency or resistance may be mild in Type 2 diabetics, however, preventing the profound spike in blood glucose seen in traditional DKA.7
The evidence suggesting a link between SGLT2 inhibitors and euglycemic DKA remains limited to case reports. Both the FDA and the European Medicine Agency have reported cases of DKA with unusually low glucose levels.4,9 Peters et al. reported 13 episodes euglycemic DKA in patients taking SGLT2 inhibitors, though most were Type 1 diabetics.10 In Japan, 28 cases of DKA or ketoacidosis in patients taking SGLT2 inhibitors have been reported as of 2015. Of these, the initial blood glucose is known in only 14 cases, but in 9 cases, it was <300 mg/dL.8
You have just signed out from one of the best shifts in your career. You feel like you were born to do this! You’re a great EM doctor! Then, you spot him, a man in a dark suit making eye contact as you walk through the lobby towards the exit. He stops and asks, “Are you Dr. About-to-get Sued?” Being named in a malpractice lawsuit is a potentially devastating, frequently unmentioned, and yet rather common event in EM. Providers may find themselves feeling isolated and ashamed, questioning their career choice regardless of the trial outcome. Members of the ALiEM Wellness Think Tank recently spoke with Dr. Gita Pensa about how to find resilience in EM despite involvement in a lawsuit. We provide the full podcast and a summary below.