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M2E Too! Mellick's Multimedia EduBlog
The M2E Too! Blog by Larry Mellick, MD, presents important clinical pearls using multimedia.

By its name, M2E Too! acknowledges that it is one of many emergency medicine blogs, but we hope this will serve as a creative commons for emergency physicians.

Wednesday, July 01, 2015

Ketamine is a fascinating drug with multiple potential applications in the emergency department, but emergency physicians should consider this phencyclidine-like dissociative agent for pain management.

 

Pain, as we know, has complex mechanisms and pathways. Peripheral and central sensitization of pain pathways are recognized as part of the process of chronic and subacute pain syndromes. The NMDA receptor is central to the sensation of pain, and ketamine’s ability to centrally block the NMDA receptor is widely recognized and accepted as the mechanism for pain relief.

 

Ketamine is rapidly distributed into the brain and other highly perfused tissues. Multiple reports in the literature describe the successful use of ketamine for refractory chronic pain. One report indicated that half of patients treated with subanesthetic doses of ketamine had up to three weeks of relief. (Pain Med 2012;13[2]:263.)

 

Now, there is growing interest among emergency physicians in the use of low-dose ketamine infusions for a wide variety of pain syndromes and etiologies. (Ann Emerg Med 2015 March 26; http://bit.ly/1BnqlIQ.) Low-dose ketamine is increasingly being used in our emergency department. Slow infusions over 20 minutes of these low doses (0.25 mg/kg) avoids the dysphoria that sometimes occurs with ketamine.

 

Thankfully, intravenous lorazepam rapidly resolves these complaints when the side effects occasionally occur. These videos demonstrate three patients with very different but severe chronic pain syndromes who responded nicely to slow infusions of low-dose ketamine.

 

Click here to watch low-dose ketamine infusions for cancer pain.

 

Click here to watch low-dose ketamine infusions for peripheral neuropathy pain.

 

Click here to watch low-dose ketamine infusions for sickle cell pain.

 

 

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Monday, June 01, 2015

Targeted or targetoid rashes are one specific rash presentation that is commonly seen and occurs with at least three conditions. Other conditions have target-like lesions, but by far the most common are acute annular urticaria or urticaria multiforme, erythema multiforme, and serum sickness-like rashes (SSLR).

 

Unlike true serum sickness, SSLR is not a type III reaction, and frank arthritis, hypocomplementemia, vasculitis, and nephropathy are not typically seen. These rashes have significant overlap in presentation and appearance, and they are frequently confused for each other. Nevertheless, it is possible to tease out unique characteristics that allow the clinician to differentiate among the three conditions.

 

The classic skin lesion of erythema multiforme is a target or iris lesion characterized by concentric erythematous rings separated by rings of near-normal color. The lesion size may range from 2 mm to 20 mm. The other conditions have lesions that appear similar and present as annular and polycyclic wheals with central clearing or ecchymotic or purpuric centers.

 

We were able to capture in the videos below visual images and historical accounts of two different patients presenting with targetoid lesions that were most consistent with urticaria multiforme and serum sickness-like conditions.

 

Click here to watch Dr. Mellick diagnose targetoid rashes on arms and legs.

 

Click here to watch Dr. Mellick diagnose the urticarial multiforme rash.

 

Dr. Mellick is a professor of emergency medicine and pediatrics at Georgia Regents University in Augusta, the former chairman of emergency medicine at Georgia Regents Health System, and a professor of emergency medicine and pediatrics at Georgia Regents Medical Center and Children’s Hospital of Georgia.

 

 

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Friday, May 01, 2015

My father was a small-town preacher. I heard the Bible verse that begins with the phrase “For the wages of sin is death” many, many times. Admittedly, it comes to mind at least once every shift I work in the ED. The cyanotic and apneic heroin overdose patient dropped off by “friends,” the drunk driver who just killed someone, or the pack-a-day cigarette smoker receiving news of lung cancer are all examples of self-destructive scenarios that might stimulate this memory.

 

I had read about levamisole-adulterated cocaine causing a flesh-destructive vasculitis, but had not seen a patient with this condition until recently. That patient allowed the two videos included with this blog because she wanted others to know about this condition. My father’s words did come to mind again, but I felt nothing but compassion for this weeping middle-aged cocaine addict seeking help for the painful necrotic lesions on her ears, nose, and face.

 

Levamisole-induced vasculitis has been known since the 1970s. Levamisole was originally an anthelmintic agent that was later found to have significant immunomodulatory properties. It was used in cancer therapy and to treat various skin conditions and immunological renal diseases for a time, but the FDA withdrew it from the human market in 1999. Unfortunately, this veterinary medicine has found a fairly widespread role as an adulterant in illicit cocaine since 2003.

 

Levamisole not only “cuts” the drug, it potentiates the stimulant effects of cocaine by prolonging the action of catecholamines in the neuronal synapse and increasing the reuptake-inhibition effect of cocaine. The metabolites of levamisole also have a stimulatory effect.

 

Unfortunately, levamisole is responsible for inducing antibodies (p-ANCA, C-ANCA, and others) that cause a distinctive vasculopathic purpura typically involving the ears, nose, cheeks, and extremities. Treatment usually begins with intravenous steroids and opiates and discontinuation of cocaine.

 

Click here to watch video.

 

Click here to watch video. 

 

 

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Tuesday, March 31, 2015

More than once, I’ve heard colleagues and residents make the statement, “I’m no good at pediatric rashes.” The truth is that there is usually a large waste basket of “nonspecific viral exanthems” that are easy to bring to closure in your conversation with parents, and then there are similar-appearing rashes associated with drug reactions.

 

Then there are the targeted lesions, which include acute annular urticaria or urticaria multiforme, erythema multiforme minor, and serum sickness-like rashes that are frequently confused for each other.

 

My simplistic approach continues by acknowledging that there are rare rashes like id reactions, Gianotti-Crosti rashes, fixed drug reactions, and others that may require an iPhone video or picture consultation with your dermatologist.

 

Finally, there is the subset of relatively easy rashes that are common and specific in appearance. (Chicken pox or varicella used to fit into this category, but now they’re so rare that most young physicians have never seen a case.) Nevertheless, other rash-associated conditions include hand-foot-mouth disease, scarlet fever, pityriasis rosea, and shingles that are easy to master, and you won’t forget after seeing one or two cases. This month’s videos demonstrate three of those relatively common pediatric rashes (scarlet fever, pityriasis rosea, and shingles.)

 

EPs are frequently heard to say they aren’t good at diagnosing pediatric rashes, but this video will help identify shingles in children.

 

Some rashes aren’t difficult to diagnose once you’ve seen a case or two. This video helps with diagnosing strep.

 

Once you see a case of pityriasis rosea fever, you won’t forget the rash. This video shows you what to look for.


Read more about rashes in our archive.

 

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Monday, March 02, 2015

Emergency medicine, since its inception as a specialty, has continuously redefined itself by absorbing intellectual and procedural expertise traditionally owned by other specialties. Whether it is performing advanced airway procedures formerly unique to anesthesia, reducing and splinting various orthopedic dislocations and fractures, or managing urological emergencies such as priapism or otolaryngology procedures, emergency physicians have relentlessly expanded their procedural expertise. Some consultants have forced our hands by delaying or being reluctant to see these emergencies in the emergency department. Others willingly ceded procedural expertise of routine procedures because of their busy practice demands. Nevertheless, in the end, our advances in a variety of procedures will continue. Short, high-quality procedure videos such as these included in Emergency Medicine News will play an important role in teaching new procedural skills just in time or even real-time.

 

Click here to watch a video of a tracheostomy tube replacement. 

 

Click here to watch a video of a naspharyngoscope placement.
 
Click here to watch a video of a needle aspiration of peritonsillar abscess.
 

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About the Author

Larry Mellick, MD
Dr. Mellick is a professor of emergency medicine and pediatrics at Georgia Regents University in Augusta, the former chairman of emergency medicine at Georgia Regents Health System, and a professor of emergency medicine and pediatrics at Georgia Regents Medical Center and Children’s Hospital of Georgia.