Hypokalemic Periodic Paralysis in the ED

Hypokalemic Periodic Paralysis in the ED

Case Presentation

A middle-aged man with a two days history of weakness in his legs. The patient works as a construction worker and is used to conducting heavy physical activity.

After a thorough history and examination, the weakness was reported in the lower extremities with a power of 2/5, whereas the power in upper extremities was 4.5/5, Achilles tendon reflex was reduced, plantar response and other reflexes were intact, with normal sensation. Rest of the examination is unremarkable.

The vitals are within normal ranges, Blood investigations include – Urea and electrolytes, liver and renal function, full blood count, thyroid function tests, creatine kinase, urine myoglobin, vitamin B12 and folic acid levels.

Potassium level was 1.7 mEq/L (normal 3.5-5.5), and all other parameters were within normal ranges.

The ECG showed inverted T waves and the presence of U waves. An Example of an ECG:

Hypokalemic periodic paralysis is a rare disorder that may be hereditary as the primary cause, or secondary due to thyroid disease, strenuous physical activity, a carbohydrate-rich meal and toxins. The patients are mostly of Asian origin.

The most common presentation is of symmetrical weakness in lower limbs, with a low potassium level and ECG changes of hypokalemia. The patients may have a history of similar weaknesses which may be several years old. An attack may be triggered by infections, stress, exercise and other stress-related factors.

The word ‘weakness’, can lead to physicians thinking about stroke, neurological deficits and other life-threatening illnesses such as spinal cord injuries associated with high morbidity and mortality which need to be ruled out in the ED.

In this case, history and examination are vital. Weakness in other parts of the body, a thorough neurological examination are important aspects.

Patients are monitored and treated with potassium supplements (oral/Intravenous) until the levels normalize. ECG monitoring is essential, as cardiac function may be affected. 

The patient should be examined to assess the strength and should be referred for further evaluation and to confirm the diagnosis.

The differential diagnosis for weakness in lower limb include :

  1. Spinal cord disease (https://iem-student.org/spine-injuries/)
  2. Guillain barre syndrome
  3. Toxic myositis
  4. Trauma
  5. Neuropathy
  6. Spinal cord tumour

References

Cite this article as: Sumaiya Hafiz, UAE, "Hypokalemic Periodic Paralysis in the ED," in International Emergency Medicine Education Project, September 7, 2020, https://iem-student.org/2020/09/07/hypokalemic-periodic-paralysis-in-the-ed/, date accessed: October 23, 2020

Triads in Medicine – Rapid Review for Medical Students

triads in medicine

One of the most convenient ways of learning and remembering the main components of disease and identifying a medical condition on an exam are Triads, and medical students/interns/residents swear by them.

Be it a question during rounds, a multiple-choice exam question to be solved, or even in medical practice, the famous triads help physicians recall important characteristics and clinical features of a disease or treatment in an instant.

Since exam season is here, this could serve as a rapid review to recall the most common medical conditions.

While there are a vast number of triads/pentads available online, I have listed the most important (high-yy) ones that every student would be asked about at least once in the duration of their course.

1) Lethal Triad also known as The Trauma Triad of Death
Hypothermia + Coagulopathy + Metabolic Acidosis

2) Beck’s Triad of Cardiac Tamponade
Muffled heart sounds + Distended neck veins + Hypotension

3) Virchow’s Triad – Venous Thrombosis
Hypercoagulability + stasis + endothelial damage

4) Charcot’s Triad – Ascending Cholangitis
Fever with rigors + Right upper quadrant pain + Jaundice

5) Cushing’s Triad – Raised Intracranial Pressure
Bradycardia + Irregular respiration + Hypertension

6) Triad of Ruptured Abdominal Aortic Aneurysm
Severe Abdominal/Back Pain + Hypotension + Pulsatile Abdominal mass

7) Reactive Arthritis
Can’t See (Conjunctivitis) + Can’t Pee (Urethritis) + Can’t Climb a Tree (Arthritis)

8) Triad of Opioid Overdose
Pinpoint pupils + Respiratory Depression + CNS Depression

9) Hakims Triad – Normal Pressure Hydrocephalus
Gait Disturbance + Dementia + Urinary Incontinence

10) Horner’s Syndrome Triad
Ptosis + Miosis + Anydrosis

11) Mackler’s Triad – Oesophageal Perforation (Boerhaave Syndrome)
Vomiting + Lower Thoracic Pain + Subcutaneous Emphysema

12) Pheochromocytoma
Palpitations + Headache + Perspiration (Diaphoresis)

13) Leriche Syndrome
Buttock claudication + Impotence + Symmetrical Atrophy of bilateral lower extremities

14) Rigler’s Triad – Gallstone ileus
Gallstones + Pneumobilia + Small bowel obstruction

15) Whipple’s Triad – Insulinoma
Hypoglycemic attack + Low glucose + Resolving of the attack on glucose administration

16) Meniere’s Disease
Tinnitus + Vertigo + Hearing loss

17) Wernicke’s Encephalopathy- Thiamine Deficiency
Confusion + Ophthalmoplegia + Ataxia

18) Unhappy Triad – Knee Injury
Injury to Anterior Cruciate Ligament + Medial collateral ligament + Medial or Lateral Meniscus

19) Henoch Schonlein Purpura
Purpura + Abdominal pain + Joint pain

20) Meigs Syndrome
Benign ovarian tumor + pleural effusion + ascites

21) Felty’s Syndrome
Rheumatoid Arthritis + Splenomegaly + Neutropenia

22) Cauda Equina Syndrome
Low back pain + Bowel/Bladder Dysfunction + Saddle Anesthesia

23) Meningitis
Fever + Headache + Neck Stiffness

24) Wolf Parkinson White Syndrome
Delta Waves + Short PR Interval + Wide QRS Complex

25) Neurogenic Shock
Bradycardia + Hypotension + Hypothermia

Further Reading

Cite this article as: Sumaiya Hafiz, UAE, "Triads in Medicine – Rapid Review for Medical Students," in International Emergency Medicine Education Project, June 12, 2020, https://iem-student.org/2020/06/12/triads-in-medicine/, date accessed: October 23, 2020

Epistaxis on a Flight

Epistaxis On A Flight

A couple of days ago, a friend told me about an incident that had occurred on a plane where a middle-aged man was found to have epistaxis (bleeding from the nose) midway between a 4-hour flight. Although epistaxis has various degrees of severity and only a small percent are life-threatening, the sight of blood, no matter the amount, is a cause of panic and anxiety for everyone. Hence, the cabin crew was called and helped in managing the patient until the flight landed.

Some of the causes of epistaxis on a flight are dryness in the nose due to changes in cabin pressure and air conditioning. Other causes depend on patients’ previous health problems, which may include medications such as warfarin, bleeding disorders, nose-picking.

As important as it is to learn the emergency management of epistaxis in a hospital setting, often you come across a scenario such as this, in your daily life and its essential to know how to manage it, out of the hospital setting or even in the emergency department, while taking history or waiting to be seen.

The following are a few steps you can take for initial conservative management of epistaxis:

If the following measures fail, further medical management may be advised.

Overview

Epistaxis is acute hemorrhage from the nose, nostrils, nasopharynx, and can be either anterior or posterior, depending on the source of bleeding. It is one of the most common Otolaryngological Emergencies.

Anterior bleeds are the most common, and a large proportion is self-limited. The most common site is ‘Little’s area’ also known as Kiesselbach’s plexus (Anastomosis of three primary vessels occurs in this area: the septal branch of the anterior ethmoidal artery; the lateral nasal branch of the sphenopalatine artery; and the septal branch of the superior labial branch of the facial artery).

Posterior bleeds are less common and occur from posterolateral branches of the sphenopalatine artery and can result in significant hemorrhage.

Causes of epistaxis

Nose picking, dryness, allergic or viral rhinitis, foreign body, trauma, medications (anticoagulants), platelet disorders, nasal neoplasms, hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu disease), aspirin.

Assessment and Management

References and Further Reading

Alter Harrison. Approach to the adult epistaxis. [December 24th, 2019] from:  https://www.uptodate.com/contents/approach-to-the-adult-with-epistaxis

Cite this article as: Sumaiya Hafiz, UAE, "Epistaxis on a Flight," in International Emergency Medicine Education Project, December 27, 2019, https://iem-student.org/2019/12/27/epistaxis-on-a-flight/, date accessed: October 23, 2020

A mnemonic for the care of critical ED patients

A mnemonic for the care of critical ED patients

Emergency departments and critical care units are very busy areas with a high turnover of patients, as well as the urgency of care provided with even smaller details matter in routine patient management. There should be strong efforts to improve the quality of patient care and to reduce medical errors, which are dangerous in such complex and busy areas. Thus, to support safe, effective care and closed-loop communication, patient medical records should be up to date so that timely care should be provided in emergency departments and ICU. Different protocols, standard operating procedures, checklist and physician rounds are all part of the attempt to improve clinical care. Very strict care is mandatory irrespective of the cause in critically ill and emergency patients. For the same, a shortened mnemonics for remembering elements of routine care is very important both in the emergency department and ICU. This is very important in daily clinical rounds.

In 2005, Jean Vincent came up with FAST HUGS, an abbreviated mnemonic for remembering important issues to look for in critical patients. It was basically a CME exercise from its origins and developed into an interesting article (1).

Subsequently, after four years, it became a valuable tool, and Vincent and Hatton upgraded the mnemonic to FAST HUGS BID in 2009 by including additional components of spontaneous breathing trial, bowel care, indwelling catheter removal and de-escalation of antibiotics (2).

  • Feeding/fluids
  • Analgesia
  • Sedation
  • Thromboprophylaxis
  • Head up position
  • Ulcer prophylaxis
  • Glycemic control
  • Spontaneous breathing trial
  • Bowel care
  • Indwelling catheter removal
  • De-escalation of antibiotics

Chris Nickson on Life In The Fast Lane Critical Care Compendium (CCC) expanded it further to FAST HUGS IN BED Please, with additional environmental control for delirium, a reminder to de-escalate therapies finishing it with psychosocial support (3).

FAST HUGS IN BED Please

The above version was meant and applied in the emergency department or the intensive care unit as per Dr. Chris Nickson, last update July 23, 2019:3

Finally, this same concept can be easily applied in the emergency department as a modification FAST HUGS IN BED ED.

FAST HUGS IN BED ED will help both undergraduate medical students and residents in emergency medicine and critical care to revise and remember important areas of care. This has enormous benefits in a busy emergency resuscitation room as well as in complex ICU care settings.

References and Further Reading

  1. Vincent, Jean-Louis. “Give your patient a fast hug (at least) once a day.” Critical care medicine 33.6 (2005): 1225-1229.
  2. Vincent, William R., and Kevin W. Hatton. “Critically ill patients need “FAST HUGS BID”(an updated mnemonic).” Critical care medicine 37.7 (2009): 2326-2327.
  3. Dr. Chris Nickson, last update July 23, 2019, Life in the Fastlane – https://litfl.com/fast-hugs-in-bed-please/
Cite this article as: Temesgen Beyene, Ethiopia, "A mnemonic for the care of critical ED patients," in International Emergency Medicine Education Project, December 16, 2019, https://iem-student.org/2019/12/16/a-mnemonic-for-the-critical-ed-patients/, date accessed: October 23, 2020

Countries Recognize Emergency Medicine as a Specialty

As health care professionals working on Emergency medicine, our history is still being written. Let’s say you would like to learn which countries officially recognize Emergency Medicine (EM) as a specialty, and want to make a beautiful interactive infographic depicting these countries with their official EM recognition years (Because, why not?). It should be an easy task, right? WRONG.

What is your guess?

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How many countries recognize Emergency Medicine as a specialty?

Even though it seems like a simple question which should have a clear answer, the answer is somewhat of a conundrum. There are a few difficulties for the answer. First of all, what is the definition of “recognition”? Could it be possible to consider having an EM residency program or the presence of EM specialists in a country as recognition? Probably not. Secondly, some of the countries recognize EM as a specialty but the exact year of recognition is unclear. Also, the answer may vary between articles and makes it hard to choose one. To make things clear, we have accepted the definition of “recognition” as a country’s official approvement of Emergency Medicine as a primary specialty. Countries recognizing EM as a supra-specialty (such as Switzerland) were also considered as a recognizing country in our list.

Anyway, we have rolled our sleeves up and dug deep. Many articles and tweets later, we had all the data available on this topic. To the best of our knowledge, this is the first time an article or blog post lists EM’s official dates of recognition for the entire world. We have also taken one step further and showed them on a neat interactive map.

So here we go: As of 05/2019, there are 82 countries in the world which recognize EM as a specialty. 13 countries from Africa, 27 countries from Asia, 13 countries from the America, 27 countries from Europe, and two countries from Oceania recognize EM.

As a well-known fact, the first two countries to recognize EM as a specialty are the United States and the U.K. Which are the latest? Germany and Denmark are the most recent of these countries, as both of them recognized EM in 2018. Perhaps, one year later, there will be new countries which welcome EM specialty. Who knows?

Shall we take a look at the current situation in an eye-pleasing way? Of course! You can view our interactive map right here. You can view maps with colors corresponding to the years of EM recognition for each country in the world (darker the color, earlier the date) in Figure 1. You can also view continental maps for Africa, Asia, Americas, Europe and Oceania in Figures 2, 3, 4, 5, 6, respectively.

iEM world

Figure 1. Countries Recognize Emergency Medicine as a Specialty

WORLD

iEM world

Figure 2. Countries Recognize Emergency Medicine as a Specialty

AFRICA

iEM world

Figure 3. Countries Recognize Emergency Medicine as a Specialty

ASIA

iEM world

Figure 4. Countries Recognize Emergency Medicine as a Specialty

AMERICA

iEM world

Figure 5. Countries Recognize Emergency Medicine as a Specialty

EUROPE

iEM world

Figure 6. Countries Recognize Emergency Medicine as a Specialty

OCEANIA

For the ones who believe nothing is better than a list, all countries are listed in alphabetical order in Table 1. Table 1. List of counties which recognize EM as a specialty (alphabetical order).

Table 1. List of counties which recognise EM as a specialty (alphabetical order).
Country Name Year of Recognition
Albania 2011
Argentina 2010
Australia 1993
Bahrain 2001 *
Belgium 2005
Bulgaria 1996
Botswana 2011
Brazil 2016
Canada 1979
Chile 2013
Colombia 2005
Costa Rica 1994
Croatia 2009
Cuba 2000 §
Czech Republic 2013
Denmark 2018
Dominican Republic 2000
Egypt 2003
Estonia 2015
Ethiopia 2010
Finland 2012
France 2015
Georgia 2015
Germany 2018 #
Ghana 2015
Greece 2017 #
Haiti 2014
Hong Kong 1997
Hungary 2003
Iceland 1992
India 2009
Iran 2002
Iraq 2013
Ireland 2003
Israel 2009
Italy 2008
Japan 2003
Jordan 2003
Kenya 2017
Laos 2017
Lebanon 2012
Libya 2013
Lithuania 2013
Malaysia 2002
Malawi 2010
Malta 2004
Mexico 1986
Morocco 2002
Myanmar 2012
Netherlands 1998
New Zealand 1995
Nicaragua 1993
Norway 2017
Oman 1999
Pakistan 2010
Peru 1999
Philippines 1988
Poland 1999
Qatar 2000
Romania 1999
Rwanda 2013
Saudi Arabia 2001
Serbia 1992
Singapore 1984
Slovakia 2003
Slovenia 2006
South Africa 2004
South Korea 1996
Sri Lanka 2011
Sudan 2011
Sweden 2015
Switzerland 2009 #
Taiwan 1998
Tanzania 2011
Thailand 2003
Tunisia 2005
Turkey 1993
United Arab Emirates 2004
United Kingdom 1993
United States 1972
Vietnam 2010
Yemen 2000

* Exact year of EM recognition in Bahrain is unknown and establishing of The Bahrain Emergentologist Association (BEMASSO) in 2004 accepted as the recognition year for this infographic.
§ Cuba has an EM/intensive care unit (ICU) training program which was begun in 2000.
# EM is considered as a supra-specialty in Germany, Greece, and Switzerland.

That is all for now! Please feel free to share it and comment on this list. Also, please tell us if we had any countries left behind or if there were any mistakes. EM family grows every day!

Together we are stronger!

References and Further Reading

  • Swanson RC, Soto NR, Villafuerte AG, Emergency medicine in Peru, J Emerg Med. 2005 Oct;29(3):353-6, DOI:10.1016/j.jemermed.2005.02.013
  • Garcia-Rosas C, Iserson KV, Emergency medicine in México, J Emerg Med. 2006 Nov;31(4):441-5, DOI:10.1016/j.jemermed.2006.05.024
  • Al-Azri NH, Emergency medicine in Oman: current status and future challenges,Int J Emerg Med. 2009 Dec 11;2(4):199-203. doi: 10.1007/s12245-009-0143-6.
  • Sakr M, Wardrope J, Casualty, accident and emergency, or emergency medicine, the evolution, J Accid Emerg Med. 2000 Sep;17(5):314-9.
  • Pek J.H., Lim S.H., Ho H.F., Emergency medicine as a specialty in Asia, Acute Med Surg. 2016 Apr; 3(2): 65–73, doi: 10.1002/ams2.154
  • Fleischmann T, Fulde G.,Emergency medicine in modern Europe, Emerg Med Australas. 2007 Aug;19(4):300-2.
  • Partridge R., Emergency medicine in Cuba: an update, Am J Emerg Med. 2005 Sep;23(5):705-6, DOI: 10.1016/j.ajem.2005.03.006.
  • MacFarlane C, van Loggerenberg C, Kloeck W.,International EMS systems in South Africa–past, present, and future,Resuscitation. 2005 Feb;64(2):145-8,DOI:10.1016/j.resuscitation.2004.11.003
Cite this article as: Ibrahim Sarbay, Turkey, "Countries Recognize Emergency Medicine as a Specialty," in International Emergency Medicine Education Project, May 13, 2019, https://iem-student.org/2019/05/13/countries-recognize-emergency-medicine/, date accessed: October 23, 2020

Unbearable Attraction of Emergency Medicine

Where This Attraction Come From?

Emergency Medicine! It is maybe the most desired specialty all around the world. Countries are rapidly changing their systems to modern emergency medical care. Residency trained emergency physicians are the cornerstone of this change across the globe. Today, more than 65 countries have recognized Emergency Medicine specialty. The demand is still so big, and all systems are facing to Emergency Physician shortage. However, it is not the reason why thousands of students/interns apply for a single position every year. 

This summer many new Emergency Medicine residents will start their new career. They are the winners! They chose the best specialty ever. They chose to be the advocate for their patients. They chose the challenge themselves to save a life, many lives. 

Want to understand more “why?” We have 3 chapter to share with you. You may prefer to read or listen. Every medical student and intern should know these facts; the facts that make our specialty unique. 

Emergency Medicine: A Unique Specialty

Will Sanderson, Danny Cuevas,
and Rob Rogers

Imagine walking into the hospital to start your day – ambulances are blaring, the waiting room is clamoring, babies are crying…

Choosing the Emergency Medicine As A Career

C. James Holliman

The specialty of Emergency Medicine (EM) is a great career choice for medical students and interns. In August 2013, I celebrated my 30th year in full-time EM clinical practice…

Thinking Like an Emergency Physician

Joe Lex

Why are we different? How do we differentiate ourselves from other specialties of medicine? We work in a different environment in different hours and with different patients more than any other specialty. Our motto is “Anyone, anything, anytime.”

Core EM Clerkship Topics

Continue reading “Core EM Clerkship Topics”