Chikungunya

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POTD- Wacky Wednesday! This one brought to you from the curious mind of our very own TINA NGUYEN!!!  And why is it wacky? Well because we rarely see it and can hardly say it... today were talking  

What is it?

  • Alpha virus transmitted by mosquitoes Aedes aegyoti and aedes albopictus

Where is it?

  • Endemic to West Africa and Latin America but seen EVERYWHERE!

    • Think of it in recent immigrants or travelers

How do you get it?

  • Mosquito bite, blood products, organ transplant, maternal fetal ( a/w miscarriage, highest transmission if infected during the intrapartum period)

Symptoms:

  • Acute: 1-14 days
    • Fever- High grade, lasts 3-5days
    • Polyarthralgias- bilateral, symmetric, distal>proximal
    • Skin- Nonspecific, 40-75% pts, macpap rash, pruritis
  • Complications:
    • Resp failure, myocarditis, acute hepatitis, renal failure, CNS involvement, hemorrhage, death
    • Prersistent or relapsed disease with arthralgias, tenosynotvitis, raynauds

Workup:

  • Labs: Lymphopenia, thrombocytopenia, Elevated transaminases, ^Cr
  • Diagnosis: RT-PCR if within 1-7days of onset after ELISA testing
    • R/o Dengue and Zika also!

Treatment:

  •  Supportive care- Rest, fluids, acetaminophen, NSAIDs
    • Careful of ASA or NSAIDs until you r/o dengue as they can increase severity of disease
  • Immune-compromised- Consider broad spectrum abx and consult ID!!

 

Sources: CDC, WHO, UpToDate

 

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Hyperkalemia in Digoxin Toxicity

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This topic was brought to our attention today by Dr. Glassman.
5 Facts about Digoxin: 
1) It is a cardiac glycoside that increases inotropy and automaticity
2) Treats tachyarrhythmias and CHF
3) Mechanism of action: inhibits the Na/K ATPase pump
4) Renally cleared (look out for pts with new renal failure on digoxin)
5) It's one of those tricky drugs with a narrow therapeutic index!
Net effect: increased intracellular Na+ and Ca2+ levels; increased extracellular K+ levels
Dig Tox by Systems: 
GI: nausea, vomiting, diarrhea, abd pain
Cardiovascular: palpitations, syncope, dyspnea
CNS: confusion/delirium, dizziness, altered color perception
Metabolic: hyperkalemia (early sign!)
Time Course of Toxicity: 
GI effects seen @ 2-4 hr
Life-threatening cardiovascular complications @ 8-12 hr
Peak serum levels @ 6 hr
More on the Cardiac Effects...
Digoxin can cause a multitude of dysrhythmias!
- Frequent PVCs (most common) including ventricular bigeminy and trigeminy
- Sinus bradycardia
- Slow atrial fibrillation
- Any degree of AV block (due to increased vagal effects at the AV node)
- SVT (due to the enhanced automaticity) with SLOW ventricular response (again due to increased vagal effects at the AV node)
- VT
Confused? Yet this makes some sense. If you've watched any lectures by Amal Mattu, he calls hyperkalemia the Syphilis of EKGs, referring to its status as the "Great Imitator" of many diverse pathologies. Gross, right? And what does digoxin cause? Hyperkalemia!
Some Possible EKG Findings in Dig Tox: 

This unique "scooped" or "swooping" depression of the ST segment memorably resembles the shape of Salvador Dali's mustache.

Paroxysmal atrial tachycardia with 2nd degree AV block AND frequenct PVCs

Atrial flutter with a slow ventricular rate due to AV nodal blockade by digoxin

Treatment: 

You'll find that digoxin-induced arrhythmias are usually refractory to standard therapies.

Ex: bradycardia resistant to atropine and pacing

The solution? Digibind (digoxin Fab fragments)! There are dosing formulas (ask your pharmacist for help!) but if in doubt, start with 5 vials for stable acute toxicity and 10 vials for unstable acute toxicity (ex: accidental ingestion by a child). For chronic toxicity, start with 2 vials empirically and titrate up.

References:

Life In the Fast Lane

UpToDate

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Hanging Injuries

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I'll start off the month with a POTD inspired by a case from the other day… 36 yo M bib NYPD after he was found passed out in a jail cell after being arraigned with a ligature mark around his neck…He wound up being ok and was transferred out for inpatient psych but lets talk hanging injuries…

CLASSIFICATION:

EVALUATION:

  • ABCs but of course!! Low threshold to intubate for airway protection as they can crash without warning!!
  • Look for pain to larynx, cough, stridor, muffled voice, resp distress, AMS, petechiae, abrasions/lacerations/contusions to neck and hard/soft signs of vascular injury
  • High risk of ARDS and cerebral edema so judicious fluids- don’t go flooding them!
  • Altered? Tube and treat for increased ICP
  • High risk of arrhythmias

IMAGING: CT brain (cerrebal hypoxia), CT c-spine (mc= c2 spondylolithesis) and consider CTA head/neck for vascular injury!

DISPO:

  • ALL should be admitted for 24hr obs as high risk for delayed airway and pulmonary complications

Sources:

Life in the Fast Lane. http://lifeinthefastlane.com/trauma-tribulation-016/

EM-Docs

Medscape, UpToDate

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