This blog intends to create an educational platform for Emergency Physicians, sharing EM related basics and updates. Every week, I come up with a new post which can be in the form of written material with references/other FOAMed resources OR a 15-20 minute podcast with a written summary. My goal with this blog is to improve Resident education, Academic EM and Flipping the classroom. To get the maximum benefit from this blog, subscribe by your e-mail.
I have completed bits of my EM training from India. Currently I am boarded with credentials from Christian Medical College, Vellore and also from the prestigious Royal College of Emergency Medicine, UK. I am currently working in London as an A&E doctor, trying to appreciate the differences in the practise and culture of Emergency Medicine across different healthcare systems. I have always been an avid FOAMed supporter because FOAMed played an indispensable role during the days of my initial training. Through this blog, I aspire to disseminate knowledge and stay up to date with the EM literature.
A blend of Proton Pump Inhibitor and anti emetics is something that a bulk of patients get, sometimes without a reason. I think it is time to step back and always question ourselves prior to ordering these medications. More importantly, we need to get rid of the thought that pushes us to prescribe thinking that "if there is no benefit, they are probably not going to hurt". Let us look at some possible downsides of these drugs.
Proton Pump Inhibitors
They are used for a myriad of concerns such as headache, vomiting, nausea, abdominal pain (regardless of presumed etiology), eradicate H. Pylori, ZE Syndrome, gastroenteritis, GERD and so on.. While a single dose may not have much side effects but in the long run, there are potential downsides that might accompany these medications. In addition, these are freely available as over the counter preparations and therefore, have the possibility of being misused.
Possible Adverse Effects with long term use (other than GI Distress and Headache)
1. Hypocalcemia, Osteoporosis and Fractures Probably because dietary calcium absorption is dependent upon an acidic environment in the gut.
2. Hypomagnesemia (May present as arrhythmias)
3. Anemia (B12 and Iron deficiency)
PPIs may also affect vitamin B12 levels because the body can’t absorb the vitamin without stomach acid to uncouple the vitamin from protein in food.
It is unlikely that patients with normal iron stores will develop iron deficiency anemia from PPI use alone. However, patients with low baseline iron stores may be more susceptible to further iron depletion with concurrent PPI therapy.
4. Increased risk of infections (Pneumonia and Clostridium Difficle)
PPIs blunt the gastric acid secretion that act as a defense mechanism against enteric bacteria. Increased gastric pH during PPI use allows for colonization of opportunistic microbes)
5. Alters the composition of gut flora
6. Interact with Clopdrogel(click here to read more on this interaction)
PPI therapy in combination with clopidogrel (Plavix) use may increase the risk of cardiac events.
Ondansetron (AKA Emeset, Zofer, Zofran)
It is a 5HT3 receptor antagonist that is frequently used for Postoperative and Chemo Induced Nausea Vomiting , also prescribed for N&V in general and gastroenteritis. It is metabolised by liver.
Concerning Adverse Effects
Headache, Dizziness, Fever
Serotonin Syndrome (with concomitant use of serotonergic meds)
1Hutchinson C, Geissler CA, Powell
JJ, Bomford A. Proton pump inhibitors suppress absorption of dietary non-haem
iron in hereditary haemochromatosis. Gut. 2007;56(9):1291–1295.
2Ito T, Jensen RT (2010). "Association
of long-term proton pump inhibitor therapy with bone fractures and effects on
absorption of calcium, vitamin B12, iron, and
magnesium". Current Gastroenterology Reports12(6):
3Focks JJ, Brouwer MA, van Oijen MG,
Lanas A, Bhatt DL, Verheugt FW (2013). "Concomitant
use of clopidogrel and proton pump inhibitors: impact on platelet function and
clinical outcome- a systematic review". Heart99(8):
4 Cardoso RN, Benjo AM,
DiNicolantonio JJ, Garcia DC, Macedo FY, El-Hayek G, et al. (2015). "Incidence
of cardiovascular events and gastrointestinal bleeding in patients receiving
clopidogrel with and without proton pump inhibitors: an updated
meta-analysis". Open Heart2 (1):
5 Lambert AA, Lam JO, Paik JJ,
Ugarte-Gil C, Drummond MB, Crowell TA (2015). "Risk of
community-acquired pneumonia with outpatient proton-pump inhibitor therapy: a
systematic review and meta-analysis". PLoS ONE10 (6):
6Corleto VD et al. Proton pump
inhibitor therapy and potential long-term harm. Current Opinion in
Endocrinology, Diabetes and Obesity. 2014 February;21(1):3-8. doi:10.1097/MED.0000000000000031PMID 24310148
7 US Food and Drug
Administration. (2012). FDA Drug Safety Communication: New information
regarding QT prolongation with ondansetron (Zofran). Retrieved from http://www.fda.gov/Drugs/DrugSafety/ucm310190.htm
8Gollapudy, Suneeta, Vikram Kumar,
and M. Saeed Dhamee. "A case of serotonin syndrome precipitated by
fentanyl and ondansetron in a patient receiving paroxetine, duloxetine, and
bupropion." Journal of clinical anesthesia 24.3 (2012):
Pituitary apoplexy (apoplexy: a sudden neurologic impairment) is a neurosurgical and endocrine emergency that constitutes a clinical syndrome caused by the rapid expansion of a pituitary adenoma secondary to ischemia and /or intratumoral hemorrhage which causes compression of the cavernous sinus, chasm, optic nerves and hormonal imbalance. The diagnosis is often delayed as approximately ~80% of these patients will have no previous history of a pituitary problem. Pituitary apoplexy may also occur in non-adenomatous or even the normal pituitary gland especially during pregnancy.
Most cases of pituitary apoplexy present in the fifth or sixth decade with a slight male preponderance and the most common presenting symptoms is sudden severe headache, which is frequently retro-orbital in location.
Because of the rich and the complex vascular system pituitary adenomas have a greater propensity to bleed in contrast to other brain tumours. The pituitary gland is located in a bony cavity called the sella turcica covered by the diaphragma sellae superiorly. It lies in close proximity with hypothalamus, optic chiasma and the cavernous sinus.
Possible reasons for a hemmorhage could be:
Rapid tumor growth that outstrips the arterial supply
Constriction of the thin vascular network and finally ischemia, necrosis and haemorrhage
Aggressive and invasive tumoral behaviour and hemorrhage
Headache (present in 95% of the cases)
Nausea and Vomiting
Changes in visual fields
Major Surgery (CABG)
Dynamic testing of pituitary gland
How is pituitary apoplexy different from Sheehan Syndrome?
Sheehan syndrome refers to pituitary apoplexy of a nontumorous gland, presumably due to postpartum arterial spasm of arterioles supplying the anterior pituitary and its stalk. Normally, the pituitary gland hypertrophies in pregnancy and this hypertrophy, combined with locally released factors, mediates vascular spasm and renders the pituitary more susceptible to infarction from compromised blood flow. It typically presents years later or as inability to lactate after delivery due to prolactin deficiency and amenorrhea due to gonadotrophin deficiency. Also, after delivery, pubic hair fail to grow, and waxy skin depigmentation develops. Signs of hypothyroidism and hypoadrenalism may develop.
Cavernous sinus thrombosis
Diagnosis and Management
MRI is the investigation of choice in a patient with suspected pituitary apoplexy. However, if a MRI scan is not possible, a dedicated pituitary CT is another alternative.
Medical treatment consists of the following:
IV Fluids and administer high-dose corticosteroids. Corticotropic deficiency is present in most patients with pituitary apoplexy and it may be life-threatening. Hydrocortisone can be administered as 100–200 mg intravenous bolus followed either by continuous intravenous infusion of 2-4 mg/hour.
Administer appropriate endocrinologic replacement therapy alone or combined with transsphenoidal surgical decompression.
Clinically, the most important endocrine dysfunction is adrenocorticotroph hormone (ACTH) deficiency. Resolution of hypersecretory states have been reported following apoplexy, also described as ‘auto-hypophysectomy’.
Management is controversial in terms of surgical intervention as some experts advocate early surgical decompression in all patients, whereas others adopt a more conservative approach for selected patients (without visual acuity or field defects and with normal consciousness). Outcome is similar with either conservative management or surgery in more recent studies. Long term with follow-up with hormonal evaluation is required to replace the deficient hormones.
Pituitary Apoplexy is a life threatening cause of acute onset headache
Maintain a high index of suspicion in any patient with acute headache and a negative conventional CT scan
Steroid replacement and maintaining the hemodynamic stability for the cornerstone of management
Ranabir, Salam, and Manash P. Baruah. “Pituitary Apoplexy.” Indian Journal of Endocrinology and Metabolism 15.Suppl3 (2011): S188–S196. PMC. Web. 17 Apr. 2016.
Rajasekaran, S., Vanderpump, M., Baldeweg, S.et al. (2011) UK guidelines for the management of pituitary apoplexy.Clinical Endocrinology, 74, 9-20.
Solomon, Adriana Elena, et al. "Pituitary apoplexy: clinical features, management and outcome. Clinical study and review of the literature." Romanian Neurosurgery 22.1 (2015): 69-77.
The World Health Organization (WHO) has updated its fact sheet on Dengue and severe dengue.
Dengue is a mosquito-borne viral disease that is transmitted by female mosquitoes mainly of the species Aedes aegypti and, to a lesser extent, Ae. albopictus. This mosquito also transmits chikungunya, yellow fever and Zika infection.
Severe dengue (also known as Dengue Haemorrhagic Fever) affects most Asian and Latin American countries and has become a leading cause of hospitalization and death among children in these regions.
The Aedes aegypti mosquito lives in urban habitats and breeds mostly in man-made containers. Unlike other mosquitoes Ae. aegyptiis a day-time feeder; its peak biting periods are early in the morning and in the evening before dusk. Female Ae. aegyptibites multiple people during each feeding period.
There are 4 distinct, but closely related, serotypes of the virus that cause dengue (DEN-1, DEN-2, DEN-3 and DEN-4). Recovery from infection by one serotype provides lifelong immunity against that particular serotype. However, cross-immunity to the other serotypes after recovery is only partial and temporary. Subsequent infections by other serotypes increase the risk of developing severe dengue.
Global Disease Burden:
The full global burden of the disease is uncertain- one estimate indicates 390 million dengue infections per year, of which 96 million manifest clinically (with any severity of disease); Another study estimates that 3.9 billion people, in 128 countries, are at risk of infection with dengue viruses.
An estimated 500 000 people with severe dengue require hospitalization each year, a large proportion of whom are children. About 2.5% of those affected die.
Dengue should be suspected when a high fever (40°C/104°F) is accompanied by 2 of the following symptoms:
pain behind the eyes
muscle and joint pains
swollen glands or
Symptoms usually last for 2–7 days, after an incubation period of 4–10 days after the bite from an infected mosquito.
Severe dengue is a potentially deadly complication due to plasma leaking, fluid accumulation, respiratory distress, severe bleeding, or organ impairment.
Warning signs of severe dengue occur 3–7 days after the first symptoms in conjunction with a decrease in temperature (below 38°C/100°F) and include:
severe abdominal pain
blood in vomit.
The next 24–48 hours of the critical stage can be lethal; proper medical care is needed to avoid complications and risk of death.
There is no specific treatment for dengue fever.
In late (December) 2015 and early 2016, the first dengue vaccine, Dengvaxia (CYD-TDV) by Sanofi Pasteur, was registered in several countries for use in individuals 9-45 years of age living in endemic areas.
The Strategic Advisory Group of Experts (SAGE) on immunization will review the dengue vaccine and recommendations are expected in April 2016.
Prevention and Control:
At present, the only method to control or prevent the transmission of dengue virus is to combat vector mosquitoes through:
preventing mosquitoes from accessing egg-laying habitats by environmental management and modification;
disposing of solid waste properly and removing artificial man-made habitats;
covering, emptying and cleaning of domestic water storage containers on a weekly basis;
applying appropriate insecticides to water storage outdoor containers;
using of personal household protection such as window screens, long-sleeved clothes, insecticide treated materials, coils and vaporizers;
improving community participation and mobilization for sustained vector control;
applying insecticides as space spraying during outbreaks as one of the emergency vector-control measures