1 00:00:00,399 --> 00:00:01,839 There was a great video once of Michael 2 00:00:01,839 --> 00:00:03,520 J. Fox, like, basically being on a talk 3 00:00:03,520 --> 00:00:05,120 show and taking a break and then taking 4 00:00:05,120 --> 00:00:07,200 his medicine and coming back out afterwards. And 5 00:00:07,200 --> 00:00:07,859 the improvement 6 00:00:08,320 --> 00:00:09,939 that you get from carvedopalevodopa 7 00:00:10,639 --> 00:00:13,585 is so dramatic. I tend to ask these 8 00:00:13,585 --> 00:00:15,425 patients, what is your dose? When did you 9 00:00:15,425 --> 00:00:17,265 last take it? And when are you due? 10 00:00:17,265 --> 00:00:18,385 And do you have it with you? If 11 00:00:18,385 --> 00:00:19,824 so, you know, just let the nurses know 12 00:00:19,824 --> 00:00:20,984 you're gonna take it. If not, I'll order 13 00:00:20,984 --> 00:00:22,864 it from the pharmacy now because it'll take 14 00:00:22,864 --> 00:00:24,625 a couple hours to get there. So the 15 00:00:24,625 --> 00:00:25,984 more you get out ahead of this, the 16 00:00:25,984 --> 00:00:27,904 more you can can make sure that these 17 00:00:27,904 --> 00:00:29,980 people stay in the happy place. 18 00:00:31,640 --> 00:00:33,799 Hi, everyone, and welcome to another episode of 19 00:00:33,799 --> 00:00:36,840 Amplify. I'm your host, Sam Michoud. Before we 20 00:00:36,840 --> 00:00:38,840 dive into this month's episode, I wanna say 21 00:00:38,840 --> 00:00:40,920 thank you for joining us, and I wanna 22 00:00:40,920 --> 00:00:43,685 remind you that you can go to ebmedicine.net 23 00:00:43,685 --> 00:00:45,704 where you will find our three journals, 24 00:00:46,005 --> 00:00:49,604 emergency medicine practice, pediatric emergency medicine practice, and 25 00:00:49,604 --> 00:00:53,125 evidence based urgent care, and a multitude of 26 00:00:53,125 --> 00:00:56,024 other resources like the EKG course, the laceration 27 00:00:56,164 --> 00:01:00,239 course, interactive clinical pathways, just tons of information 28 00:01:00,619 --> 00:01:02,699 to support your practice and help you in 29 00:01:02,699 --> 00:01:04,700 your patient care. And if you're not a 30 00:01:04,700 --> 00:01:06,939 subscriber, try us out, and we will meet 31 00:01:06,939 --> 00:01:09,420 all of your CME needs. And now let's 32 00:01:09,420 --> 00:01:10,799 jump into this month's episode. 33 00:01:11,465 --> 00:01:13,304 Alright, ladies and gentlemen. Welcome back to the 34 00:01:13,304 --> 00:01:13,804 podcast. 35 00:01:14,104 --> 00:01:16,984 I'm Sam Ashu, one of your hosts. And 36 00:01:16,984 --> 00:01:19,244 on the other end of the microphone is 37 00:01:20,024 --> 00:01:22,424 doctor T. R. Eckler. Could not be more 38 00:01:22,424 --> 00:01:24,825 excited to talk about all of these rare 39 00:01:24,825 --> 00:01:26,680 and interesting actually, maybe not as rare as 40 00:01:26,680 --> 00:01:30,200 I thought, neurologic conditions. Yeah. For sure. And 41 00:01:30,200 --> 00:01:33,740 today, we are having another episode of trivia 42 00:01:33,799 --> 00:01:35,819 with TR as we talk about 43 00:01:36,200 --> 00:01:39,319 neurological diseases in the emergency department. This is 44 00:01:39,319 --> 00:01:42,715 the May 2025 issue issue of emergency medicine 45 00:01:42,715 --> 00:01:45,674 practice called the emergency department management of patients 46 00:01:45,674 --> 00:01:47,775 with complications of chronic neurological 47 00:01:48,075 --> 00:01:51,195 disease, specifically, really just three neurological diseases. We're 48 00:01:51,195 --> 00:01:54,700 gonna talk about Parkinson's, myasthenia gravis, and multiple 49 00:01:54,700 --> 00:01:55,200 sclerosis. 50 00:01:55,819 --> 00:01:58,140 And I'm sure if you're listening to this 51 00:01:58,140 --> 00:02:01,260 podcast, you know someone with at least one 52 00:02:01,260 --> 00:02:02,560 of the three of these. 53 00:02:02,859 --> 00:02:04,939 I have a family member with Parkinson's. I 54 00:02:04,939 --> 00:02:06,879 have multiple friends with multiple sclerosis. 55 00:02:07,394 --> 00:02:09,395 I don't know anybody with myasthenia gravis, but 56 00:02:09,395 --> 00:02:11,655 that doesn't mean it's not an important disease, 57 00:02:11,794 --> 00:02:13,574 and we're gonna cover it today. 58 00:02:13,955 --> 00:02:16,754 But before we do, trivia question number one. 59 00:02:16,754 --> 00:02:18,675 Are you ready? I'm ready. 68 year old 60 00:02:18,675 --> 00:02:20,294 man with Parkinson's disease 61 00:02:20,719 --> 00:02:22,819 is brought to the ED with chest pain. 62 00:02:22,879 --> 00:02:25,280 He missed his morning medications, and he's been 63 00:02:25,280 --> 00:02:28,020 waiting in the ED for, drum roll, please, 64 00:02:28,080 --> 00:02:30,400 eight hours, which would never happen in your 65 00:02:30,400 --> 00:02:32,319 ED. I understand, t r. But just in 66 00:02:32,319 --> 00:02:34,415 case, we're just gonna set the bar there 67 00:02:34,415 --> 00:02:36,594 eight hours. And while attempting to stand, 68 00:02:37,455 --> 00:02:39,155 he falls and sustains 69 00:02:39,455 --> 00:02:40,915 a subdural hematoma 70 00:02:41,294 --> 00:02:42,754 in your emergency department. 71 00:02:43,534 --> 00:02:47,375 Which ED management principle was most likely overlooked 72 00:02:47,375 --> 00:02:49,580 in this scenario? So we're not casting blame, 73 00:02:49,639 --> 00:02:51,319 but if you were gonna pick one, what 74 00:02:51,319 --> 00:02:53,400 would it be? A, you didn't give him 75 00:02:53,400 --> 00:02:55,500 aspirin for chest pain. B, 76 00:02:56,199 --> 00:02:57,580 you should avoid anticholinergic 77 00:02:57,959 --> 00:02:58,459 medications 78 00:02:59,000 --> 00:02:59,979 in this population. 79 00:03:00,280 --> 00:03:00,780 C, 80 00:03:01,305 --> 00:03:03,805 you should evaluate troponin levels promptly 81 00:03:04,264 --> 00:03:06,044 and not let them wait for eight hours, 82 00:03:06,664 --> 00:03:07,164 d, 83 00:03:07,704 --> 00:03:09,484 maintaining the patient's Parkinson's 84 00:03:09,784 --> 00:03:11,004 medication schedule 85 00:03:11,544 --> 00:03:12,364 is important, 86 00:03:12,824 --> 00:03:13,644 or, e, 87 00:03:14,199 --> 00:03:16,439 performing a head CT on arrival for all 88 00:03:16,439 --> 00:03:19,479 Parkinson's disease patients is the critical piece that 89 00:03:19,479 --> 00:03:20,219 you missed. 90 00:03:20,519 --> 00:03:21,959 Given how hard it is to get a 91 00:03:21,959 --> 00:03:24,519 radiology read these days, I'm not scanning every 92 00:03:24,519 --> 00:03:27,865 Parkinson's patient. Not a chance. Wrong reason, but 93 00:03:27,865 --> 00:03:28,525 good choice. 94 00:03:28,905 --> 00:03:31,625 My chest pains are more often GERD in 95 00:03:31,625 --> 00:03:33,885 this stressful time, so I actually am struggling 96 00:03:33,944 --> 00:03:35,705 to make sure I give all my appropriate 97 00:03:35,705 --> 00:03:37,305 chest pains aspirin. Because I think if I 98 00:03:37,305 --> 00:03:38,985 gave every chest pain aspirin, I would make 99 00:03:38,985 --> 00:03:41,145 so much GERD so much worse that I 100 00:03:41,145 --> 00:03:43,069 just can't do that. But I will tell 101 00:03:43,069 --> 00:03:45,230 you that of the few medications that I 102 00:03:45,230 --> 00:03:45,969 worry about, 103 00:03:46,430 --> 00:03:47,569 Parkinson's medicines 104 00:03:48,110 --> 00:03:50,050 are so important to time well 105 00:03:50,750 --> 00:03:53,550 because the improvement it gives the patient in 106 00:03:53,550 --> 00:03:54,449 their stability 107 00:03:54,830 --> 00:03:57,615 and their movement and their coordination is just, 108 00:03:57,694 --> 00:03:59,694 it's remarkable. There was a great video once 109 00:03:59,694 --> 00:04:01,534 of Michael J Fox, like, basically being on 110 00:04:01,534 --> 00:04:02,974 a talk show and taking a break and 111 00:04:02,974 --> 00:04:04,655 then taking his medicine and coming back out 112 00:04:04,655 --> 00:04:06,194 afterwards. And the improvement 113 00:04:06,655 --> 00:04:08,194 that you get from carvedopalevodopa 114 00:04:08,974 --> 00:04:10,594 is so dramatic. I 115 00:04:10,980 --> 00:04:12,819 tend to ask these patients, what is your 116 00:04:12,819 --> 00:04:14,819 dose? When did you last take it? And 117 00:04:14,819 --> 00:04:16,020 when are you due? And do you have 118 00:04:16,020 --> 00:04:17,459 it with you? If so, you know, just 119 00:04:17,459 --> 00:04:18,660 let the nurses know you're gonna take it. 120 00:04:18,660 --> 00:04:20,100 If not, I'll order it from the pharmacy 121 00:04:20,100 --> 00:04:21,939 now because it'll take a couple hours to 122 00:04:21,939 --> 00:04:23,459 get there. So the more you get out 123 00:04:23,459 --> 00:04:25,300 ahead of this, the more you can can 124 00:04:25,300 --> 00:04:27,355 make sure that these people stay in the 125 00:04:27,355 --> 00:04:29,595 happy place that is their their peak and 126 00:04:29,595 --> 00:04:32,394 trough. Yeah. Absolutely. And that is really the 127 00:04:32,394 --> 00:04:35,854 perfect answer to the question. Well done. The 128 00:04:35,915 --> 00:04:36,415 ideal 129 00:04:36,954 --> 00:04:39,115 is to keep them on their regular schedule. 130 00:04:39,115 --> 00:04:42,360 That's anybody with Parkinson's disease. And Parkinson's, as 131 00:04:42,360 --> 00:04:45,240 the article authors point out, is really more 132 00:04:45,240 --> 00:04:46,220 often a comorbidity. 133 00:04:46,600 --> 00:04:49,080 It's not typically the reason that they're presenting 134 00:04:49,080 --> 00:04:51,080 to the emergency department. It's not something you're 135 00:04:51,080 --> 00:04:53,399 gonna diagnose in the emergency department, but it 136 00:04:53,399 --> 00:04:56,584 is a frequent comorbidity in the elderly in 137 00:04:56,584 --> 00:04:58,044 that kinda Medicare 138 00:04:58,504 --> 00:04:59,805 geriatric population. 139 00:05:00,185 --> 00:05:01,884 And carbidopa levodopa 140 00:05:02,185 --> 00:05:04,904 is the most frequently prescribed medication in the 141 00:05:04,904 --> 00:05:07,064 way of treatment. There is no cure for 142 00:05:07,064 --> 00:05:08,204 Parkinson's disease, 143 00:05:08,579 --> 00:05:10,980 and the disease is caused by a central 144 00:05:10,980 --> 00:05:12,600 deficiency of dopamine, 145 00:05:13,139 --> 00:05:14,759 which leads to 146 00:05:15,139 --> 00:05:18,199 all kinds of symptoms, including things like rigidity, 147 00:05:18,660 --> 00:05:19,479 poor movement, 148 00:05:19,779 --> 00:05:22,345 poor balance, puts them at risk for falls. 149 00:05:22,564 --> 00:05:23,625 And unfortunately, 150 00:05:24,004 --> 00:05:25,144 carbidopa levodopa 151 00:05:25,604 --> 00:05:28,564 is something that can wear off while they're 152 00:05:28,564 --> 00:05:31,285 in the emergency department, and then they can 153 00:05:31,285 --> 00:05:34,824 become more symptomatic. And that complicates matters because 154 00:05:35,310 --> 00:05:36,830 now you're dealing with a patient who came 155 00:05:36,830 --> 00:05:38,670 in for some other reason, whether it's chest 156 00:05:38,670 --> 00:05:40,830 pain or ulcerative mental status or confusion or 157 00:05:40,830 --> 00:05:43,230 UTI, and now you've thrown in these other 158 00:05:43,230 --> 00:05:43,730 symptoms, 159 00:05:44,110 --> 00:05:46,830 and it becomes unclear. Are they worsening because 160 00:05:46,830 --> 00:05:48,454 of the UTI or infection, infection? 161 00:05:49,794 --> 00:05:51,535 Or do they just need their medication? So 162 00:05:51,535 --> 00:05:53,634 getting that information upfront and making sure they 163 00:05:53,634 --> 00:05:55,574 stay on their schedule, critical action. 164 00:05:55,875 --> 00:05:56,615 Well done. 165 00:05:57,074 --> 00:05:59,175 I also think just as a an aside, 166 00:05:59,314 --> 00:06:00,995 as I learn more and more in this 167 00:06:00,995 --> 00:06:02,514 job, I used to just think of this 168 00:06:02,514 --> 00:06:04,569 as, like, a stability and a strength thing 169 00:06:04,569 --> 00:06:05,949 related to their Parkinson's. 170 00:06:06,410 --> 00:06:09,610 But the autonomic dysfunction that they develop and 171 00:06:09,610 --> 00:06:11,689 the nature of the lability of their blood 172 00:06:11,689 --> 00:06:14,009 pressure is something that especially as you talk 173 00:06:14,009 --> 00:06:15,930 about when they get, you know, some kind 174 00:06:15,930 --> 00:06:18,014 of illness or some other thing, like they're 175 00:06:18,014 --> 00:06:19,935 overdosed on their heart failure meds and they're 176 00:06:19,935 --> 00:06:20,595 too dry, 177 00:06:20,975 --> 00:06:24,095 that that is exacerbated by the autonomic dysfunction 178 00:06:24,095 --> 00:06:26,095 of their Parkinson's. And they're more likely to 179 00:06:26,095 --> 00:06:28,254 syncable episodes. They're more likely to have their 180 00:06:28,254 --> 00:06:30,095 blood pressure run high, and they'll take more 181 00:06:30,095 --> 00:06:31,375 medicine than they should have, and then it 182 00:06:31,375 --> 00:06:33,919 runs real low. So you gotta be cautious 183 00:06:33,919 --> 00:06:35,279 in the blood pressure on these people. And 184 00:06:35,279 --> 00:06:37,599 I think orthostatic vitals on these people are 185 00:06:37,599 --> 00:06:38,959 a great thing to think about just so 186 00:06:38,959 --> 00:06:40,240 you can have a sense before you try 187 00:06:40,240 --> 00:06:42,000 to safely discharge them as to if they're 188 00:06:42,000 --> 00:06:43,839 gonna fall because they're unstable or if they're 189 00:06:43,839 --> 00:06:45,600 gonna fall because their blood pressure's gonna drop 190 00:06:45,600 --> 00:06:47,134 through the floor. Yeah. And it you know, 191 00:06:47,134 --> 00:06:48,514 they get this dystonia, 192 00:06:49,055 --> 00:06:50,514 which can often 193 00:06:51,055 --> 00:06:51,875 be mimicked 194 00:06:52,334 --> 00:06:54,115 by dopamine antagonists. 195 00:06:54,415 --> 00:06:55,535 So, you know, we used to think of 196 00:06:55,535 --> 00:06:57,475 things like typical antipsychotics, 197 00:06:58,014 --> 00:07:00,014 but now there's evidence that even the atypical 198 00:07:00,014 --> 00:07:00,514 antipsychotics 199 00:07:00,894 --> 00:07:04,060 and even some seizure medicines like valproic acid 200 00:07:04,439 --> 00:07:06,220 and antiemetics like metoclopramide, 201 00:07:06,920 --> 00:07:09,980 some of those can actually cause similar dystonia. 202 00:07:10,279 --> 00:07:13,500 And so in an elderly person who has 203 00:07:13,720 --> 00:07:14,939 dystonic symptoms, 204 00:07:15,425 --> 00:07:18,384 you may end up seeing that initial presentation 205 00:07:18,384 --> 00:07:21,665 of Parkinson's, or it may be a medication 206 00:07:21,665 --> 00:07:22,404 side effect, 207 00:07:22,705 --> 00:07:23,205 or 208 00:07:23,745 --> 00:07:25,764 it could be actually Parkinson's 209 00:07:26,225 --> 00:07:28,625 made worse by a medication that's been recently 210 00:07:28,625 --> 00:07:31,399 prescribed. I thought there was a excellent case 211 00:07:31,399 --> 00:07:34,120 example in the article about an elderly patient 212 00:07:34,120 --> 00:07:35,659 who was recently prescribed metoprolol, 213 00:07:36,039 --> 00:07:38,219 because it turns out beta blockers can affect 214 00:07:38,439 --> 00:07:40,519 dopamine. Not very much, mind you, but in 215 00:07:40,519 --> 00:07:42,759 somebody who has Parkinson's, that may be just 216 00:07:42,759 --> 00:07:44,704 enough to tip the scales and make their 217 00:07:44,704 --> 00:07:47,105 symptoms worse. And so it's just as important 218 00:07:47,105 --> 00:07:49,185 to get the history about their medication dosing 219 00:07:49,185 --> 00:07:51,425 schedule as it is to ask about new 220 00:07:51,425 --> 00:07:53,685 meds and new prescriptions that they've started. 221 00:07:54,064 --> 00:07:57,339 The carbidopa levodopa is the most typical medication 222 00:07:57,339 --> 00:07:59,500 we prescribe. It's a combination of two medicines, 223 00:07:59,500 --> 00:08:03,839 levodopa, which increases dopamine levels, and carbidopa, 224 00:08:04,379 --> 00:08:06,480 which prevents the peripheral 225 00:08:07,019 --> 00:08:09,439 conversion of levodopa to dopamine 226 00:08:10,095 --> 00:08:12,495 so that you don't get peripheral effects. It 227 00:08:12,495 --> 00:08:12,995 increases 228 00:08:14,095 --> 00:08:15,235 the levodopa conversion 229 00:08:15,775 --> 00:08:19,214 in the CNS, so carbidopa doesn't cross the 230 00:08:19,214 --> 00:08:22,275 blood brain barrier, and levodopa does. So levodopa 231 00:08:22,415 --> 00:08:24,979 will go into the CNS and get converted 232 00:08:24,979 --> 00:08:28,180 to dopamine and therefore help with Parkinson's and 233 00:08:28,180 --> 00:08:28,759 the symptoms 234 00:08:29,060 --> 00:08:31,959 of poor quantities of dopamine in the central 235 00:08:32,019 --> 00:08:34,339 nervous system. That's how the medication works. And 236 00:08:34,339 --> 00:08:37,539 it comes in short acting and extended release 237 00:08:37,539 --> 00:08:40,065 preparations, so it's important to know which ones 238 00:08:40,065 --> 00:08:42,384 your patients are taking. Sometimes people will take 239 00:08:42,384 --> 00:08:44,384 this once or twice a day. Sometimes they 240 00:08:44,384 --> 00:08:46,065 will take it up to five times a 241 00:08:46,065 --> 00:08:47,745 day. And so it can be pretty easy 242 00:08:47,745 --> 00:08:48,644 to miss doses 243 00:08:49,024 --> 00:08:52,259 in a emergency department visit, even if it's 244 00:08:52,259 --> 00:08:53,539 just for a couple hours. It doesn't have 245 00:08:53,539 --> 00:08:55,220 to be an eight hour stay. They also 246 00:08:55,220 --> 00:08:57,620 mentioned that some cases for severe patients, they'll 247 00:08:57,620 --> 00:09:00,500 they'll basically administer it continuously by NG tube. 248 00:09:00,500 --> 00:09:02,419 Yes. So this where you've got a patient 249 00:09:02,419 --> 00:09:04,440 that's got an NG tube that's been dislodged, 250 00:09:04,914 --> 00:09:06,914 and they seem like they're starting to have 251 00:09:06,914 --> 00:09:08,674 symptoms that are getting worse. It's something to 252 00:09:08,674 --> 00:09:11,075 consider that they they could have been getting 253 00:09:11,075 --> 00:09:12,914 this, and then they can get a withdrawal 254 00:09:12,914 --> 00:09:13,414 syndrome 255 00:09:13,715 --> 00:09:16,914 from basically not having their carbidopa levodopa, which 256 00:09:16,914 --> 00:09:17,815 is called Parkinsonian 257 00:09:18,195 --> 00:09:18,695 hyperpyrexia 258 00:09:19,315 --> 00:09:19,815 syndrome, 259 00:09:20,190 --> 00:09:23,710 which kinda resembles neuroleptic malignant syndrome. And it 260 00:09:23,710 --> 00:09:25,790 is something that that I think I would 261 00:09:25,790 --> 00:09:28,029 immediately be thinking, oh, this person's getting septic. 262 00:09:28,029 --> 00:09:30,269 This person's getting, you know, altered. And and 263 00:09:30,269 --> 00:09:31,870 I think that'd be the the thing I'd 264 00:09:31,870 --> 00:09:33,284 wanna take away is, did they run out 265 00:09:33,284 --> 00:09:35,125 of their carbidopa levodopa, and have they been 266 00:09:35,125 --> 00:09:36,404 off of it for a couple of days? 267 00:09:36,404 --> 00:09:38,884 Or did they suddenly have this administration of 268 00:09:38,884 --> 00:09:40,884 continuous through their NG tube get stopped, and 269 00:09:40,884 --> 00:09:43,365 that's why they're developing this syndrome. It's something 270 00:09:43,365 --> 00:09:44,964 to keep in your differential. For sure. In 271 00:09:44,964 --> 00:09:47,639 fact, I thought the feeding tube thing was 272 00:09:47,639 --> 00:09:50,759 pretty interesting. I've never seen a patient with 273 00:09:50,759 --> 00:09:53,660 a PEG tube or a PEG j tube 274 00:09:53,960 --> 00:09:57,660 that is a continuous infusion of carbidopa levodopa. 275 00:09:58,040 --> 00:10:00,600 The idea certainly makes sense, but they drive 276 00:10:00,600 --> 00:10:03,764 home the point that opposed to someone who 277 00:10:03,764 --> 00:10:06,324 normally might dislodge a feeding tube and be 278 00:10:06,324 --> 00:10:08,884 a candidate for just replacement in the ED 279 00:10:08,884 --> 00:10:10,664 with a Foley or something temporary, 280 00:10:11,125 --> 00:10:14,279 this is someone who cannot miss that infusion. 281 00:10:14,339 --> 00:10:15,940 And so you have to make sure that 282 00:10:15,940 --> 00:10:18,500 if they're unable to get the continuous infusion, 283 00:10:18,500 --> 00:10:20,339 you have a plan for what is going 284 00:10:20,339 --> 00:10:22,440 to then take its place until they can, 285 00:10:22,580 --> 00:10:24,440 especially if they can't hook up that tubing 286 00:10:24,500 --> 00:10:27,345 again into whatever temporary device you've placed. 287 00:10:27,824 --> 00:10:30,404 And secondly, that if you end up intubating 288 00:10:30,625 --> 00:10:34,144 someone with Parkinson's disease, that placing an NG 289 00:10:34,144 --> 00:10:36,225 tube and making sure they stay on their 290 00:10:36,225 --> 00:10:39,824 medication regimen is critically important because even in 291 00:10:39,824 --> 00:10:40,485 the ICU, 292 00:10:40,940 --> 00:10:43,100 they can go through the withdrawals from their 293 00:10:43,100 --> 00:10:45,659 medication, and this can affect how long they 294 00:10:45,659 --> 00:10:47,179 stay on the ventilator, whether or not they 295 00:10:47,179 --> 00:10:48,779 can be extubated, and so on and so 296 00:10:48,779 --> 00:10:50,860 forth down the road. So, you know, NG 297 00:10:50,860 --> 00:10:53,954 or some kind of enteric modality for providing 298 00:10:53,954 --> 00:10:57,074 that medication is very, very important. All great 299 00:10:57,074 --> 00:10:58,694 points that the authors brought up. 300 00:10:59,315 --> 00:11:01,475 And then, of course, there is one other 301 00:11:01,475 --> 00:11:04,194 modality for treating Parkinson's disease, and that's central 302 00:11:04,194 --> 00:11:04,694 stimulation 303 00:11:05,074 --> 00:11:08,194 with deep brain stimulators. So sometimes patients will 304 00:11:08,194 --> 00:11:10,029 come in where they've tried carbidopalevodopa, 305 00:11:10,730 --> 00:11:13,050 and it's been unsuccessful or just partially successful, 306 00:11:13,050 --> 00:11:14,670 and they have a deep brain stimulator. 307 00:11:15,050 --> 00:11:17,129 And in that scenario, it's just like any 308 00:11:17,129 --> 00:11:19,290 other stimulator device. You need to make sure 309 00:11:19,290 --> 00:11:20,649 it's on. You need to make sure it's 310 00:11:20,649 --> 00:11:22,264 functioning. You need to make sure they haven't 311 00:11:22,264 --> 00:11:24,924 been through a recent MRI or device adjustment 312 00:11:25,304 --> 00:11:27,304 that has affected the settings, and now they're 313 00:11:27,304 --> 00:11:29,784 actually going through acute withdrawal or being under 314 00:11:29,784 --> 00:11:31,944 dosed. So all things to keep in mind 315 00:11:31,944 --> 00:11:34,184 when someone with Parkinson's presents to the emergency 316 00:11:34,184 --> 00:11:36,820 department. So don't miss their meds. Make sure 317 00:11:36,820 --> 00:11:38,759 that they're getting it even if they're NPO 318 00:11:38,980 --> 00:11:39,720 or intubated. 319 00:11:40,100 --> 00:11:42,659 Make sure their stimulator or their PEG j 320 00:11:42,659 --> 00:11:45,480 tube is working and is still hooked up. 321 00:11:45,860 --> 00:11:49,059 Look for those physical signs of Parkinson's disease, 322 00:11:49,059 --> 00:11:50,279 which include rigidity, 323 00:11:50,924 --> 00:11:51,424 bradykinesia, 324 00:11:51,804 --> 00:11:53,644 which is really just they're very slow to 325 00:11:53,644 --> 00:11:56,544 move. They'll have tremors typically in one extremity, 326 00:11:56,684 --> 00:11:58,125 and then they'll have this kind of stooped 327 00:11:58,125 --> 00:12:00,605 over posture that comes late in development. And 328 00:12:00,605 --> 00:12:03,644 then, orostatic hypotension, like you mentioned, especially if 329 00:12:03,644 --> 00:12:05,325 they're coming in with syncope, this is a 330 00:12:05,325 --> 00:12:06,465 very common complaint. 331 00:12:07,459 --> 00:12:09,459 And if you're blessed enough to have physical 332 00:12:09,459 --> 00:12:12,179 therapy in the emergency department, this is one 333 00:12:12,179 --> 00:12:14,919 case where their assessment can certainly be exceedingly 334 00:12:14,980 --> 00:12:17,639 helpful early on because you can take someone 335 00:12:17,860 --> 00:12:19,459 who might be a good candidate to go 336 00:12:19,459 --> 00:12:21,159 home. You know, they have a mild UTI, 337 00:12:21,220 --> 00:12:23,174 not a big deal, but this has exacerbated 338 00:12:23,315 --> 00:12:25,954 their Parkinson's symptoms, and their orthostatic hypotension is 339 00:12:25,954 --> 00:12:28,115 worse, and their movement is a lot worse, 340 00:12:28,115 --> 00:12:29,954 and now they're a huge fall risk. And 341 00:12:29,954 --> 00:12:32,434 you might not have the time to pull 342 00:12:32,434 --> 00:12:34,995 that out of your history and physical, but 343 00:12:34,995 --> 00:12:37,860 a therapist would be an exceptionally good way 344 00:12:38,259 --> 00:12:40,419 to objectify that and give you some evidence 345 00:12:40,419 --> 00:12:42,419 that this person actually needs to be admitted 346 00:12:42,419 --> 00:12:43,079 to the hospital. 347 00:12:43,860 --> 00:12:46,100 Alright. Here's another trivia question for you since 348 00:12:46,100 --> 00:12:48,039 we just completed the Parkinson's discussion. 349 00:12:48,500 --> 00:12:50,980 The deficiency of dopamine that occurs in the 350 00:12:50,980 --> 00:12:54,195 brain with Parkinson's disease occurs in which part 351 00:12:54,195 --> 00:12:55,475 of the brain? Now if you have the 352 00:12:55,475 --> 00:12:57,394 article, there's a great little image, but I'm 353 00:12:57,394 --> 00:12:59,875 gonna give you five choices. Here we go. 354 00:12:59,875 --> 00:13:00,774 The amygdala, 355 00:13:01,554 --> 00:13:02,455 the cerebellum, 356 00:13:03,315 --> 00:13:04,054 the hippocampus, 357 00:13:04,835 --> 00:13:06,294 the substantia nigra, 358 00:13:06,740 --> 00:13:07,639 or the thalamus? 359 00:13:08,019 --> 00:13:10,100 Which one of those areas is the area 360 00:13:10,100 --> 00:13:11,319 that loses the dopaminergic 361 00:13:11,699 --> 00:13:12,199 neurons? 362 00:13:12,899 --> 00:13:14,179 Can I tell you, I was worried that 363 00:13:14,179 --> 00:13:16,259 you were gonna give me the larger structure 364 00:13:16,259 --> 00:13:18,500 around the substantia nigra, and I was worried 365 00:13:18,500 --> 00:13:19,940 because then you start I'm like, well, where 366 00:13:19,940 --> 00:13:21,539 is he going? But substantia nigra is the 367 00:13:21,539 --> 00:13:24,434 answer. It's always their substantial nigra isn't as 368 00:13:24,434 --> 00:13:26,434 substantial as it used to be, and that's 369 00:13:26,434 --> 00:13:28,274 the problem. And that's why they need to 370 00:13:28,274 --> 00:13:30,754 have somebody put really expensive fancy wires up 371 00:13:30,754 --> 00:13:32,674 there to make it, you know, get a 372 00:13:32,674 --> 00:13:35,220 little more substantial. There you go. Very good. 373 00:13:35,299 --> 00:13:37,220 Alright. One more question. I covered this earlier, 374 00:13:37,220 --> 00:13:38,439 but let's see if you were listening. 375 00:13:38,819 --> 00:13:41,539 Which best describes the role of carbidopa in 376 00:13:41,539 --> 00:13:44,740 the treatment of Parkinson's disease? One, it acts 377 00:13:44,740 --> 00:13:46,360 on dopaminergic receptors. 378 00:13:46,819 --> 00:13:49,639 Two, it blocks dopamine reuptake 379 00:13:50,019 --> 00:13:50,919 in the brain. 380 00:13:51,664 --> 00:13:52,804 Three, it enhances 381 00:13:53,504 --> 00:13:55,605 central conversion of dopamine. 382 00:13:56,784 --> 00:14:00,245 Four, it inhibits peripheral breakdown of levodopa. 383 00:14:01,024 --> 00:14:04,384 Or lastly, it replaces deficient dopamine in the 384 00:14:04,384 --> 00:14:05,605 central nervous system. 385 00:14:06,559 --> 00:14:08,559 I think it's four. It is four. It 386 00:14:08,559 --> 00:14:11,360 inhibits the peripheral breakdown of levodopa so you 387 00:14:11,360 --> 00:14:14,879 don't get any peripheral nervous system symptoms or 388 00:14:14,879 --> 00:14:17,360 side effects, and the levodopa ends up getting 389 00:14:17,360 --> 00:14:20,339 converted centrally. You are absolutely correct, sir. 390 00:14:20,904 --> 00:14:22,985 I wanna just make a plug here for 391 00:14:22,985 --> 00:14:25,625 the students out there, both young and old. 392 00:14:25,625 --> 00:14:27,544 I think this is such a cool medicine 393 00:14:27,544 --> 00:14:29,384 to look at from a history of medicine 394 00:14:29,384 --> 00:14:31,625 standpoint because we knew that we had to 395 00:14:31,625 --> 00:14:34,120 get more dopamine into these patients, but we 396 00:14:34,120 --> 00:14:35,959 knew we had to figure out a way 397 00:14:35,959 --> 00:14:38,459 to get it into their central nervous system. 398 00:14:38,519 --> 00:14:41,159 And I think just the the biochemical research 399 00:14:41,159 --> 00:14:42,919 and the trials and the history of, like, 400 00:14:42,919 --> 00:14:45,399 the the creation of this medicine is just 401 00:14:45,399 --> 00:14:46,220 an unbelievable 402 00:14:46,679 --> 00:14:48,845 miracle that is something that I think is 403 00:14:48,845 --> 00:14:50,605 worth looking at because I think it's easy 404 00:14:50,605 --> 00:14:53,164 to lose track in the era of modern 405 00:14:53,164 --> 00:14:55,325 medicine of all the interesting miracles that you 406 00:14:55,325 --> 00:14:57,004 just casually get to use on a daily 407 00:14:57,004 --> 00:14:59,085 basis, and you don't know the full background 408 00:14:59,085 --> 00:15:00,990 story too. So I think this is a 409 00:15:00,990 --> 00:15:03,149 good one to to look into and enjoy 410 00:15:03,149 --> 00:15:05,070 a little deep dive into the things that 411 00:15:05,070 --> 00:15:06,350 we didn't used to have that now we 412 00:15:06,350 --> 00:15:08,610 do, kinda like insulin. Great point. 413 00:15:08,990 --> 00:15:10,610 Alright. The second disease 414 00:15:11,070 --> 00:15:11,649 is myasthenia 415 00:15:12,110 --> 00:15:15,884 gravis, And this disease, unlike Parkinson's, is autoimmune 416 00:15:16,904 --> 00:15:18,925 in origin. And people have autoantibodies 417 00:15:19,384 --> 00:15:22,925 that attack their nicotinic receptors on the postsynaptic 418 00:15:23,144 --> 00:15:24,345 membrane. And if you don't know what I'm 419 00:15:24,345 --> 00:15:26,105 talking about, there's a great image in the 420 00:15:26,105 --> 00:15:26,605 article 421 00:15:26,980 --> 00:15:29,860 for exactly where this is taking place, and 422 00:15:29,860 --> 00:15:30,759 this causes 423 00:15:31,220 --> 00:15:31,720 muscular 424 00:15:32,179 --> 00:15:32,679 weakness. 425 00:15:33,139 --> 00:15:36,120 And in its most critical form, it causes 426 00:15:36,259 --> 00:15:39,539 ventilatory failure. So it affects their patient's ability 427 00:15:39,539 --> 00:15:40,919 to breathe, to ventilate, 428 00:15:41,220 --> 00:15:44,355 and then they decompensate very quickly. And the 429 00:15:44,355 --> 00:15:47,014 most common triggers for patients who have myasthenia 430 00:15:47,235 --> 00:15:50,115 gravis, even when it's controlled and treated, would 431 00:15:50,115 --> 00:15:51,495 be things like infection, 432 00:15:52,115 --> 00:15:52,615 medications, 433 00:15:52,915 --> 00:15:55,409 especially the ones that we're used to hearing 434 00:15:55,409 --> 00:15:56,710 about, things like fluoroquinolones, 435 00:15:57,169 --> 00:15:59,649 macrolides, and beta blockers. All of these can 436 00:15:59,649 --> 00:16:00,149 precipitate 437 00:16:00,610 --> 00:16:01,269 a myasthenic 438 00:16:01,649 --> 00:16:04,870 crisis, which is when someone goes from stable, 439 00:16:04,929 --> 00:16:07,825 relatively controlled myasthenia gravis to all of a 440 00:16:07,825 --> 00:16:11,184 sudden now being very weak, maybe experiencing symptoms, 441 00:16:11,184 --> 00:16:13,345 having shortness of breath, having trouble breathing, and 442 00:16:13,345 --> 00:16:16,144 then showing up in your emergency department. And 443 00:16:16,144 --> 00:16:18,465 that's when we run into trouble. So when 444 00:16:18,465 --> 00:16:20,164 it comes to myasthenia gravis, 445 00:16:20,500 --> 00:16:22,340 there are some things you can do in 446 00:16:22,340 --> 00:16:24,820 the emergency department with the patient who is 447 00:16:24,820 --> 00:16:26,820 complaining of shortness of breath or any kind 448 00:16:26,820 --> 00:16:30,360 of respiratory complaint to see if they're exacerbating 449 00:16:30,660 --> 00:16:31,860 to the point where they need to be 450 00:16:31,860 --> 00:16:32,680 in the hospital. 451 00:16:33,059 --> 00:16:35,345 So I thought the authors again did a 452 00:16:35,345 --> 00:16:37,105 great job of driving home the point that 453 00:16:37,105 --> 00:16:39,024 you can't just tell by looking at the 454 00:16:39,024 --> 00:16:41,825 person with myasthenia gravis that they're not having 455 00:16:41,825 --> 00:16:44,625 a crisis. So there there will not be 456 00:16:44,625 --> 00:16:47,445 tachypnea. They won't look like they're having respiratory 457 00:16:47,504 --> 00:16:50,480 distress. It doesn't present like, say, a COPD 458 00:16:50,620 --> 00:16:52,379 or an asthma exacerbation where you go, oh, 459 00:16:52,379 --> 00:16:54,940 that's respiratory distress. This is going to be 460 00:16:54,940 --> 00:16:57,980 quiet. It's going to be less noisy. They're 461 00:16:57,980 --> 00:17:00,620 going to look super relaxed, and it's not 462 00:17:00,620 --> 00:17:02,434 because they are relaxed. It's going to be 463 00:17:02,434 --> 00:17:05,154 because their muscles are failing, and they're unable 464 00:17:05,154 --> 00:17:06,535 to contract that musculature, 465 00:17:06,994 --> 00:17:08,914 and it's not going to present with the 466 00:17:08,914 --> 00:17:11,634 same alarms as you might expect. So their 467 00:17:11,634 --> 00:17:14,515 vital signs might be completely normal. Their oxygen 468 00:17:14,515 --> 00:17:17,160 saturation will be completely normal. And if it's 469 00:17:17,160 --> 00:17:20,759 not, that's a very, very late finding, and 470 00:17:20,759 --> 00:17:22,840 you don't wanna wait until then to make 471 00:17:22,840 --> 00:17:25,000 the diagnosis. And worse, you don't wanna send 472 00:17:25,000 --> 00:17:27,240 somebody home saying, oh, you have normal vital 473 00:17:27,240 --> 00:17:29,240 signs. You're gonna be okay, and miss the 474 00:17:29,240 --> 00:17:30,700 fact that they're having a crisis. 475 00:17:31,035 --> 00:17:33,835 So there are some tests. The diagnostic test 476 00:17:33,835 --> 00:17:36,875 of choice is the negative inspiratory force or 477 00:17:36,875 --> 00:17:39,615 the NIF, which is when they inhale 478 00:17:39,994 --> 00:17:41,134 on this device 479 00:17:41,515 --> 00:17:44,234 against pressure, and it's measured in centimeters of 480 00:17:44,234 --> 00:17:46,890 water. And anything less than 20 centimeters of 481 00:17:46,890 --> 00:17:48,750 water is indicative of a severe 482 00:17:49,369 --> 00:17:52,089 myasthenic crisis, and that person should be admitted 483 00:17:52,089 --> 00:17:54,490 to the hospital and treated and not sent 484 00:17:54,490 --> 00:17:54,990 home. 485 00:17:55,529 --> 00:17:56,970 But I thought it was pretty cool that 486 00:17:56,970 --> 00:17:59,065 they gave some alternatives there. Have you ever 487 00:17:59,065 --> 00:18:01,625 tried any of these kinda bedside alternatives when 488 00:18:01,625 --> 00:18:03,164 maybe what NIF wasn't available? 489 00:18:03,865 --> 00:18:05,465 So can we just back up for a 490 00:18:05,465 --> 00:18:08,125 second and have a moment of silence for 491 00:18:08,505 --> 00:18:09,005 edrophonium, 492 00:18:09,625 --> 00:18:10,125 which 493 00:18:11,039 --> 00:18:13,519 for my entire medical career has been if 494 00:18:13,519 --> 00:18:14,500 you wanna diagnose 495 00:18:14,880 --> 00:18:18,160 myasthenia gravis, you did a Tencelon test. And 496 00:18:18,160 --> 00:18:19,840 I looked this up today. That is that 497 00:18:19,840 --> 00:18:22,340 is Tencelon was the trade name for eidrofenium. 498 00:18:22,559 --> 00:18:24,740 That's right. And that medicine has been discontinued 499 00:18:25,174 --> 00:18:27,194 by the United States Food and Drug Association 500 00:18:27,255 --> 00:18:29,654 as of 2018. Yeah. So I have now 501 00:18:29,654 --> 00:18:31,355 arrived at the point where 502 00:18:31,815 --> 00:18:35,015 my medical education is so outdated that the 503 00:18:35,015 --> 00:18:37,515 diagnostic test of choice does not exist anymore. 504 00:18:37,734 --> 00:18:40,299 And I'm just proud to be so humbling 505 00:18:40,299 --> 00:18:42,859 and such a geriatric moment for me that 506 00:18:42,859 --> 00:18:44,539 I needed to just stare at the clouds 507 00:18:44,539 --> 00:18:47,519 for a minute and remember that time is 508 00:18:47,660 --> 00:18:49,680 fleeting and goes by so fast. 509 00:18:49,980 --> 00:18:52,059 So one moment of memory for the old 510 00:18:52,059 --> 00:18:54,245 10 swatches that I never did and because 511 00:18:54,245 --> 00:18:55,605 no one would ever give it to me, 512 00:18:55,605 --> 00:18:57,845 and I now I can't. So we are. 513 00:18:57,845 --> 00:19:00,005 That's right. So I am here to celebrate 514 00:19:00,005 --> 00:19:01,605 the fact that I do think I if 515 00:19:01,605 --> 00:19:04,404 I bother my respiratory therapy people or my 516 00:19:04,404 --> 00:19:06,884 upstairs people enough, that a NIFS machine would 517 00:19:06,884 --> 00:19:09,125 come downstairs, and I could do this. And 518 00:19:09,125 --> 00:19:11,180 I think that it intrigues me from the 519 00:19:11,180 --> 00:19:12,240 standpoint that 520 00:19:12,940 --> 00:19:15,119 I think that myasthenia 521 00:19:15,580 --> 00:19:17,440 flares I think I underappreciated 522 00:19:17,980 --> 00:19:20,059 how risky they are in terms of respiratory 523 00:19:20,059 --> 00:19:21,740 status. And I think some of these patients, 524 00:19:21,740 --> 00:19:23,684 when they're not doing well on BiPAP, I'm 525 00:19:23,684 --> 00:19:25,924 attributing it to their infection and everything else. 526 00:19:25,924 --> 00:19:27,365 But I think that's the scary part of 527 00:19:27,365 --> 00:19:29,464 these patients is, I think for, like, bad, 528 00:19:29,524 --> 00:19:32,005 you know, URIs that their intubation rates in 529 00:19:32,005 --> 00:19:33,944 studies are up to sixty percent. 530 00:19:34,484 --> 00:19:37,079 Like, the rate at which these people fail. 531 00:19:37,079 --> 00:19:38,279 And I think some of that stuff is 532 00:19:38,279 --> 00:19:40,599 in a pre BiPAP CPAP era. And I 533 00:19:40,599 --> 00:19:42,519 like to consider it in a pre COVID 534 00:19:42,519 --> 00:19:44,619 era when, like, we weren't as aggressive about 535 00:19:44,679 --> 00:19:46,839 high flow oxygen and some of the interesting 536 00:19:46,839 --> 00:19:48,679 different ways that we use BiPAP and CPAP 537 00:19:48,679 --> 00:19:50,904 now. I think that those rates are lower, 538 00:19:50,904 --> 00:19:51,724 but I still 539 00:19:52,264 --> 00:19:53,625 wanna have in the back of my mind 540 00:19:53,625 --> 00:19:55,304 the idea that I need to watch these 541 00:19:55,304 --> 00:19:57,704 patients very carefully because even if I do 542 00:19:57,704 --> 00:19:59,704 everything right, they still may need to be 543 00:19:59,704 --> 00:20:01,164 intubated. And that 544 00:20:01,559 --> 00:20:03,639 was an interesting thing for me to take 545 00:20:03,639 --> 00:20:06,039 away from this that I need to accept 546 00:20:06,039 --> 00:20:06,539 that 547 00:20:06,919 --> 00:20:08,519 that may be the endpoint for these patients 548 00:20:08,519 --> 00:20:10,039 even if I do everything right. And therefore, 549 00:20:10,039 --> 00:20:11,399 I should treat it as more something to 550 00:20:11,399 --> 00:20:13,319 plan for and less of something to think 551 00:20:13,319 --> 00:20:15,265 that I'm failing if I get there. Yeah. 552 00:20:15,265 --> 00:20:18,065 So many great points there. Absolutely. So, yes, 553 00:20:18,065 --> 00:20:21,345 the Tensilon test is gone. The diagnostic test 554 00:20:21,345 --> 00:20:23,664 nowadays is an antibody assay, and so you 555 00:20:23,664 --> 00:20:26,164 can actually test them directly for these autoimmune 556 00:20:26,224 --> 00:20:26,724 antibodies, 557 00:20:27,359 --> 00:20:30,240 and make the diagnosis that way. And, yeah, 558 00:20:30,240 --> 00:20:32,660 you made some great points there about ventilatory 559 00:20:33,039 --> 00:20:35,359 management. So in an era where we used 560 00:20:35,359 --> 00:20:37,839 to only have two things, supplemental nasal cannula 561 00:20:37,839 --> 00:20:38,579 and a ventilator, 562 00:20:38,960 --> 00:20:41,625 there was a very black and white distinction 563 00:20:41,625 --> 00:20:43,544 there, a or b. But now we do 564 00:20:43,544 --> 00:20:45,325 have a lot of tools at our disposal. 565 00:20:45,544 --> 00:20:47,784 And, yes, absolutely, it's okay to use things 566 00:20:47,784 --> 00:20:50,024 like CPAP or BiPAP or high flow nasal 567 00:20:50,024 --> 00:20:53,880 cannula or these kinda intermediate measures. They're still 568 00:20:54,019 --> 00:20:55,559 representative of respiratory 569 00:20:55,859 --> 00:20:58,599 failure. So that person is still at critically 570 00:20:58,740 --> 00:21:01,480 high risk and still needs to be treated 571 00:21:01,539 --> 00:21:02,359 for a myasthenic 572 00:21:02,660 --> 00:21:03,160 crisis. 573 00:21:03,539 --> 00:21:06,740 But, hopefully, if you can avoid intubation, they 574 00:21:06,740 --> 00:21:11,054 can then avoid those downstream complications of extended 575 00:21:11,115 --> 00:21:14,154 intubation and extended trials of extubation and so 576 00:21:14,154 --> 00:21:16,634 on and so forth. Those complications can hopefully 577 00:21:16,634 --> 00:21:18,815 be avoided by bridging with some of these 578 00:21:18,875 --> 00:21:21,194 other noninvasive measures. But I do wanna be 579 00:21:21,194 --> 00:21:24,255 clear that that all still represents respiratory failure. 580 00:21:24,529 --> 00:21:26,769 And then, you know, if you don't have 581 00:21:26,769 --> 00:21:29,250 the negative inspiratory force test, the author said 582 00:21:29,250 --> 00:21:31,970 there's actually good evidence that just doing a 583 00:21:31,970 --> 00:21:35,089 counting test can be diagnostic. And this is 584 00:21:35,089 --> 00:21:38,204 done by having the patient inhale deeply and 585 00:21:38,204 --> 00:21:40,605 then count out loud at a rate of 586 00:21:40,605 --> 00:21:43,005 two numbers per second while they breathe out. 587 00:21:43,005 --> 00:21:45,505 So take a deep breath, and then one, 588 00:21:45,724 --> 00:21:49,404 two, three, four, five, six. They should be 589 00:21:49,404 --> 00:21:52,204 able to reach 30, but anything less than 590 00:21:52,204 --> 00:21:52,704 20 591 00:21:53,220 --> 00:21:56,359 is equivalent to a severe compromise 592 00:21:56,740 --> 00:21:59,619 and equivalent to a negative inspiratory force of 593 00:21:59,619 --> 00:22:02,099 less than minus 20 centimeters of water. You 594 00:22:02,099 --> 00:22:04,419 can do the NIF, which is ideal. But 595 00:22:04,419 --> 00:22:05,859 if you can't do the NIF, do the 596 00:22:05,859 --> 00:22:08,204 counting test at the bedside with your patient. 597 00:22:08,524 --> 00:22:11,164 And if they fail that, that's just about 598 00:22:11,164 --> 00:22:11,664 diagnostic 599 00:22:12,044 --> 00:22:13,265 for a severe crisis. 600 00:22:13,884 --> 00:22:14,625 And then 601 00:22:15,164 --> 00:22:17,904 when it comes to treatment, because it's autoimmune, 602 00:22:18,444 --> 00:22:21,085 we're looking at all things at our disposal. 603 00:22:21,085 --> 00:22:23,730 Now you're likely reaching out to your neurology 604 00:22:23,730 --> 00:22:25,910 specialist at this point as you should, but 605 00:22:26,049 --> 00:22:28,289 lots of things are at their disposal, things 606 00:22:28,289 --> 00:22:30,230 like steroids, things like plasmapheresis, 607 00:22:30,850 --> 00:22:33,269 things like specific targeted immunosuppressants, 608 00:22:33,904 --> 00:22:35,424 and even things that we don't normally think 609 00:22:35,424 --> 00:22:36,404 about, like cyclosporine 610 00:22:36,784 --> 00:22:37,524 and methotrexate. 611 00:22:38,065 --> 00:22:39,684 All of these can be prescribed 612 00:22:40,065 --> 00:22:42,944 acutely, but even for long term control. So 613 00:22:42,944 --> 00:22:45,605 you might see somebody, for example, with myasthenia 614 00:22:45,744 --> 00:22:47,044 gravis who's on rituximab. 615 00:22:47,585 --> 00:22:50,390 But in the acute phase, steroids, plasmapheresis, 616 00:22:50,769 --> 00:22:51,509 and IVIG 617 00:22:51,970 --> 00:22:53,570 are kind of the mainstays for what you're 618 00:22:53,570 --> 00:22:54,930 gonna give them. And the sooner you start 619 00:22:54,930 --> 00:22:55,670 that, the better. 620 00:22:56,049 --> 00:22:58,690 Ergo, get your neurologist on the phone once 621 00:22:58,690 --> 00:23:00,150 you have their breathing stabilized. 622 00:23:01,684 --> 00:23:03,525 And I think from a rural and critical 623 00:23:03,525 --> 00:23:05,204 access standpoint, I think these are the kind 624 00:23:05,204 --> 00:23:06,265 of patients that 625 00:23:06,884 --> 00:23:09,464 they can look better on oxygen on BiPAP, 626 00:23:09,605 --> 00:23:11,765 but you're still wanting to transfer these patients 627 00:23:11,765 --> 00:23:13,684 out from your facility unless you've got an 628 00:23:13,684 --> 00:23:15,845 ICU to care for them because they're gonna 629 00:23:15,845 --> 00:23:19,099 be delicate and challenging from a, you know, 630 00:23:19,099 --> 00:23:22,700 maintaining their ventilation and oxygenation standpoint. And I 631 00:23:22,700 --> 00:23:23,759 think that you should 632 00:23:24,299 --> 00:23:26,380 move them while they're stable as opposed to 633 00:23:26,380 --> 00:23:29,180 waiting for them to become more unstable, especially 634 00:23:29,180 --> 00:23:31,660 if you have trouble managing ventilated patients in 635 00:23:31,660 --> 00:23:32,355 your setting. 636 00:23:32,755 --> 00:23:35,154 Yeah. And in a world where we still 637 00:23:35,154 --> 00:23:35,654 debate 638 00:23:36,035 --> 00:23:36,535 succinylcholine 639 00:23:36,914 --> 00:23:37,734 versus rocuronium, 640 00:23:38,355 --> 00:23:39,794 I thought the authors did a good job 641 00:23:39,794 --> 00:23:40,934 stressing that rocuronium 642 00:23:41,315 --> 00:23:42,214 should be avoided 643 00:23:42,515 --> 00:23:44,694 in this population. And succinylcholine 644 00:23:45,154 --> 00:23:47,900 should be used because it dissociates quickly. The 645 00:23:47,900 --> 00:23:49,920 one thing we don't wanna do is provide 646 00:23:50,460 --> 00:23:51,519 prolonged paralysis 647 00:23:51,900 --> 00:23:54,320 for these patients, and so succinylcholine 648 00:23:54,700 --> 00:23:57,500 is ideal. Now you can do rocheronium with 649 00:23:57,500 --> 00:23:59,625 a reversal agent if you really want to 650 00:23:59,785 --> 00:24:02,424 shortly after intubation. That's an option as well. 651 00:24:02,424 --> 00:24:05,305 But succinylcholine is what the authors recommended. Something 652 00:24:05,305 --> 00:24:06,125 to think about. 653 00:24:06,505 --> 00:24:08,825 I think that the biggest thing I took 654 00:24:08,825 --> 00:24:11,305 away from this, especially given the prevalence these 655 00:24:11,305 --> 00:24:14,460 days, is that myasthenia gravis patients really 656 00:24:14,839 --> 00:24:17,799 should not be exposed to Botox. That is 657 00:24:17,799 --> 00:24:20,279 one of the medications that will trigger a 658 00:24:20,279 --> 00:24:22,619 crisis for them. And I think given the 659 00:24:22,920 --> 00:24:25,765 ubiquity and ease of getting Botox, and there's 660 00:24:25,765 --> 00:24:27,125 just so many places you can get it 661 00:24:27,125 --> 00:24:29,204 now, I'm not sure everyone's gonna make sure 662 00:24:29,204 --> 00:24:31,365 you don't have myasthenia gravis. And I think 663 00:24:31,365 --> 00:24:33,605 that that's another question that I'm asking more 664 00:24:33,605 --> 00:24:35,525 and more of in my patients with weakness 665 00:24:35,525 --> 00:24:37,204 or my patients with stroke like symptoms is 666 00:24:37,204 --> 00:24:38,804 when is the last time you got some 667 00:24:38,804 --> 00:24:41,570 kind of paralytic or neurotoxin injected? 668 00:24:41,950 --> 00:24:43,869 Because I think it matters now in terms 669 00:24:43,869 --> 00:24:45,150 of trying to figure out what could be 670 00:24:45,150 --> 00:24:47,309 causing symptoms and what could be triggering things. 671 00:24:47,309 --> 00:24:49,950 Yeah. Yeah. In fact, there's a good table 672 00:24:49,950 --> 00:24:52,769 on page seven, the precipitants from myasthenic crisis. 673 00:24:53,075 --> 00:24:54,835 So fever and infection at the top of 674 00:24:54,835 --> 00:24:57,734 the list with good evidence behind that. Tapering 675 00:24:57,795 --> 00:25:00,194 of their immune modulating medication if they're undergoing 676 00:25:00,194 --> 00:25:02,035 some kind of medication change, lots of evidence 677 00:25:02,035 --> 00:25:05,474 behind that as well. Non depolarizing neuromuscular blocking 678 00:25:05,474 --> 00:25:06,934 agents and Botox 679 00:25:07,429 --> 00:25:09,910 all also have good evidence behind them. There 680 00:25:09,910 --> 00:25:12,150 is also evidence for things like beta blockers, 681 00:25:12,150 --> 00:25:13,849 calcium channel blockers, fluoroquinolones, 682 00:25:14,309 --> 00:25:14,809 aminoglycosides, 683 00:25:15,670 --> 00:25:16,170 magnesium 684 00:25:16,710 --> 00:25:19,429 supplementation. That's over the counter, so you gotta 685 00:25:19,429 --> 00:25:21,269 be careful and ask about that class of 686 00:25:21,269 --> 00:25:24,015 medicines as well. Class one a, antidysrhythmics 687 00:25:24,394 --> 00:25:25,134 and macrolides. 688 00:25:25,515 --> 00:25:27,994 And then there is some kind of soft 689 00:25:27,994 --> 00:25:30,955 evidence that penicillin even may be something that 690 00:25:30,955 --> 00:25:32,714 can precipitate a crisis. It's hard to say 691 00:25:32,714 --> 00:25:34,394 in that scenario if it's the infection that 692 00:25:34,394 --> 00:25:36,154 they're treating or if it's the penicillin, but 693 00:25:36,154 --> 00:25:37,919 either way, just know that there are a 694 00:25:37,919 --> 00:25:40,659 lot of things that can trigger a crisis. 695 00:25:40,960 --> 00:25:42,720 And you wanna ask about all of those, 696 00:25:42,720 --> 00:25:44,179 including over the counter meds. 697 00:25:44,559 --> 00:25:46,159 I'm pretty sure all these patients are allergic 698 00:25:46,159 --> 00:25:47,759 to penicillin, though, so I'm not really that 699 00:25:47,759 --> 00:25:49,759 worried about them getting a reaction. That's a 700 00:25:49,759 --> 00:25:51,759 whole another podcast right there, sir. A whole 701 00:25:51,759 --> 00:25:52,579 another podcast. 702 00:25:53,284 --> 00:25:53,784 Okay. 703 00:25:54,404 --> 00:25:56,644 Then let's get into some trivia questions. A 704 00:25:56,644 --> 00:26:00,005 41 year old man with myasthenia gravis is 705 00:26:00,005 --> 00:26:02,724 presenting with new shortness of breath. He was 706 00:26:02,724 --> 00:26:04,184 recently started on metoprolol. 707 00:26:04,884 --> 00:26:06,505 Which is the most appropriate 708 00:26:06,884 --> 00:26:08,585 immediate ED action? 709 00:26:08,950 --> 00:26:10,869 This is such a great board style question. 710 00:26:10,869 --> 00:26:14,490 The most appropriate immediate one. A, administer steroids, 711 00:26:15,029 --> 00:26:18,009 b, begin CPAP for oxygenation, 712 00:26:19,670 --> 00:26:23,369 c, discontinue metoprolol and assess respiratory function, 713 00:26:24,464 --> 00:26:24,964 d, 714 00:26:25,345 --> 00:26:28,704 order a head CT because why not, and 715 00:26:28,704 --> 00:26:31,444 and e, start empiric antibiotics. 716 00:26:32,464 --> 00:26:34,384 I think c felt like a good answer 717 00:26:34,384 --> 00:26:36,304 to me. I'd stop the metoprolol and I'd 718 00:26:36,304 --> 00:26:37,744 do some counting or see if I could 719 00:26:37,744 --> 00:26:39,664 steal a NIFs from upstairs. Perfect. That is 720 00:26:39,664 --> 00:26:42,690 the perfect answer. Yes. Administration of corticosteroids is 721 00:26:42,690 --> 00:26:46,529 not the first immediate action. Beginning CPAP is 722 00:26:46,529 --> 00:26:48,049 great if they need it, but you gotta 723 00:26:48,049 --> 00:26:50,769 assess the respiratory function first. Of course, ordering 724 00:26:50,769 --> 00:26:52,610 a random head CT is never the right 725 00:26:52,610 --> 00:26:55,125 answer unless you have an indication for it. 726 00:26:55,204 --> 00:26:57,845 And then starting empiric antibiotics is also not 727 00:26:57,845 --> 00:27:00,505 the answer. Now we did say that infection 728 00:27:00,644 --> 00:27:03,305 is something that can frequently cause an exacerbation, 729 00:27:03,765 --> 00:27:05,605 but you do have to figure out that 730 00:27:05,605 --> 00:27:07,444 they actually have the infection before you give 731 00:27:07,444 --> 00:27:09,470 them something that in and of itself might 732 00:27:09,470 --> 00:27:11,809 trigger a myasthenic crisis, like an antibiotic. 733 00:27:12,349 --> 00:27:14,750 Alright. One more question for the myasthenia gravis. 734 00:27:14,750 --> 00:27:17,009 Which of the following medications should be avoided 735 00:27:17,150 --> 00:27:19,549 in patients with myasthenia gravis due to the 736 00:27:19,549 --> 00:27:21,730 risk of exacerbating symptoms? Acetaminophen, 737 00:27:22,430 --> 00:27:22,930 amoxicillin, 738 00:27:23,644 --> 00:27:24,144 ceftriaxone, 739 00:27:24,924 --> 00:27:25,424 fluoroquinolones, 740 00:27:26,444 --> 00:27:27,585 or loratadine. 741 00:27:28,444 --> 00:27:30,304 Oh, I was gonna go with fluoroquinolones, 742 00:27:30,684 --> 00:27:33,244 d. Yes. Can't ever go wrong with blaming 743 00:27:33,244 --> 00:27:33,825 a fluoroquinolone 744 00:27:34,284 --> 00:27:35,664 for anything in medicine. 745 00:27:36,204 --> 00:27:37,744 Not in this era. No. 746 00:27:38,840 --> 00:27:41,160 Especially in this patient population. But, yes, there 747 00:27:41,160 --> 00:27:43,180 is very, very good evidence that fluoroquinolones 748 00:27:43,720 --> 00:27:46,200 can exacerbate myasthenia gravis. So that is the 749 00:27:46,200 --> 00:27:48,279 correct one. Two, just kinda parting thoughts on 750 00:27:48,279 --> 00:27:50,360 this that I thought were really interesting. One, 751 00:27:50,360 --> 00:27:53,575 I found that when you're looking at the 752 00:27:53,575 --> 00:27:57,255 very ill myasthenia gravis crisis, you have basically 753 00:27:57,255 --> 00:27:57,755 equivalent 754 00:27:58,375 --> 00:28:00,694 value in terms of improving their condition with 755 00:28:00,694 --> 00:28:01,914 IVIG and plasmapheresis. 756 00:28:02,694 --> 00:28:05,174 But there are certain populations that can't do 757 00:28:05,174 --> 00:28:07,720 one or the other. IVIG cannot be combined 758 00:28:07,720 --> 00:28:08,460 with dialysis. 759 00:28:08,920 --> 00:28:10,599 So if you've got a dialysis patient with 760 00:28:10,599 --> 00:28:13,099 myasthenia gravis, there's someone that's gonna get plasmapheresis. 761 00:28:13,880 --> 00:28:16,279 And if someone is septic, you don't wanna 762 00:28:16,279 --> 00:28:18,680 do plasmapheresis and deplete them of their antibodies 763 00:28:18,680 --> 00:28:20,599 at that time. So there's someone that's gonna 764 00:28:20,599 --> 00:28:21,259 get IVIG. 765 00:28:21,615 --> 00:28:22,755 I thought that was a valuable, 766 00:28:23,134 --> 00:28:24,335 you know, kind of thought to have in 767 00:28:24,335 --> 00:28:25,295 the back of my head as to what 768 00:28:25,295 --> 00:28:27,134 is the treatment I'm gonna want for which 769 00:28:27,134 --> 00:28:29,775 patient in here. And the other, just looking 770 00:28:29,775 --> 00:28:32,035 at the cost of some of these medications 771 00:28:32,095 --> 00:28:33,394 for myasthenia gravis, 772 00:28:33,799 --> 00:28:36,039 I think we touched on how tapering down 773 00:28:36,039 --> 00:28:37,900 their medications can cause a crisis. 774 00:28:38,359 --> 00:28:40,200 But like so many of our patients on 775 00:28:40,200 --> 00:28:40,940 blood thinners, 776 00:28:41,720 --> 00:28:44,599 it is not sometimes that they're titrating or 777 00:28:44,599 --> 00:28:46,839 going down on their medications by choice, but 778 00:28:46,839 --> 00:28:48,944 because they can't afford more of them. So 779 00:28:48,944 --> 00:28:49,684 trying to 780 00:28:50,065 --> 00:28:51,284 ask your patient honestly 781 00:28:51,585 --> 00:28:53,664 if they have their medication or if they've 782 00:28:53,664 --> 00:28:55,184 been running out or if they've been trying 783 00:28:55,184 --> 00:28:57,025 to stretch it to make it last longer 784 00:28:57,025 --> 00:28:58,544 or to make it last until their next 785 00:28:58,544 --> 00:29:01,265 refill, I think that can easily be one 786 00:29:01,265 --> 00:29:03,105 of the most common causes that precipitates these 787 00:29:03,105 --> 00:29:04,970 crises. And if you don't tease that out 788 00:29:04,970 --> 00:29:06,730 and try to figure out the supporting things 789 00:29:06,730 --> 00:29:08,409 to make sure to get them their medications, 790 00:29:08,409 --> 00:29:10,669 then we're gonna be back here very shortly. 791 00:29:10,970 --> 00:29:11,950 All great points. 792 00:29:12,490 --> 00:29:14,730 Alright. Let's jump into our third and final 793 00:29:14,730 --> 00:29:16,429 disease. This is multiple 794 00:29:16,730 --> 00:29:18,190 sclerosis or MS. 795 00:29:18,644 --> 00:29:19,465 It is another 796 00:29:19,924 --> 00:29:20,424 autoimmune 797 00:29:20,965 --> 00:29:22,744 disease, but this time targeting 798 00:29:23,205 --> 00:29:26,484 myelin or the lining of nerves is in 799 00:29:26,484 --> 00:29:29,785 the central nervous system leading to inflammation 800 00:29:30,325 --> 00:29:33,740 and eventual damage to the surrounding neurons and 801 00:29:33,740 --> 00:29:35,600 then manifesting in symptoms. 802 00:29:35,980 --> 00:29:38,320 Interestingly, it does have a female predominance 803 00:29:38,700 --> 00:29:41,200 ranging from two to three affected females 804 00:29:41,660 --> 00:29:44,880 for every affected male, and a typical presentation 805 00:29:45,019 --> 00:29:47,714 between 10 and 50 years of age with 806 00:29:47,714 --> 00:29:49,394 a peak between 20 and 30. So this 807 00:29:49,394 --> 00:29:51,654 is a disease of the relatively young, 808 00:29:52,035 --> 00:29:54,515 unlike what we just discussed with myasthenia gravis 809 00:29:54,515 --> 00:29:55,174 and Parkinson's. 810 00:29:55,554 --> 00:29:58,115 And the condition, again, has no cure, much 811 00:29:58,115 --> 00:30:00,535 like the other two conditions, but the therapies 812 00:30:00,595 --> 00:30:03,255 can decrease the frequency and the severity 813 00:30:03,690 --> 00:30:05,849 of the crises that bring them to the 814 00:30:05,849 --> 00:30:07,069 emergency department. 815 00:30:07,529 --> 00:30:10,349 A few things to know about multiple sclerosis 816 00:30:10,409 --> 00:30:12,429 in the ED specifically, the manifestations 817 00:30:12,970 --> 00:30:14,349 depend on the location 818 00:30:14,730 --> 00:30:16,669 of the neurons that are affected, 819 00:30:17,105 --> 00:30:19,904 which seems kinda silly to say. But people 820 00:30:19,904 --> 00:30:22,305 with multiple sclerosis who have it start to 821 00:30:22,305 --> 00:30:24,785 recognize, okay, I've got a new neurological symptom 822 00:30:24,785 --> 00:30:26,625 I haven't had before, and so I'm going 823 00:30:26,625 --> 00:30:28,144 to the emergency department because this is an 824 00:30:28,144 --> 00:30:29,950 MS flare. But if they come in with 825 00:30:29,950 --> 00:30:32,750 things that could be stroke mimics, most commonly, 826 00:30:32,750 --> 00:30:35,069 it's affecting the vision and optic neuritis is 827 00:30:35,069 --> 00:30:38,929 their presenting symptom. And so their neurological symptoms 828 00:30:39,069 --> 00:30:41,490 are going to map to wherever the deficiency 829 00:30:41,630 --> 00:30:43,409 is in the central nervous system. 830 00:30:43,904 --> 00:30:46,644 When it comes to treatment in the emergency 831 00:30:46,865 --> 00:30:49,025 department, making sure, of course, that they don't 832 00:30:49,025 --> 00:30:51,845 have an acute stroke or some other mimic 833 00:30:51,904 --> 00:30:53,285 going on is critical. 834 00:30:53,585 --> 00:30:56,164 The diagnosis is typically made by MRI 835 00:30:56,545 --> 00:30:59,365 and lumbar puncture if it's their first ever 836 00:30:59,759 --> 00:31:01,460 presentation for multiple sclerosis. 837 00:31:02,000 --> 00:31:04,960 And even though you're going to get MRI 838 00:31:04,960 --> 00:31:07,440 and LP, if you know the diagnosis of 839 00:31:07,440 --> 00:31:09,940 multiple sclerosis, then treatment with steroids 840 00:31:10,320 --> 00:31:13,859 is the recommended therapy and shouldn't be delayed 841 00:31:14,095 --> 00:31:16,255 pending MRI and LP. So it's not one 842 00:31:16,255 --> 00:31:18,255 of those instances where somehow if I give 843 00:31:18,255 --> 00:31:20,975 you steroids now, the LP results will be 844 00:31:20,975 --> 00:31:22,975 ruined and they can't use them later on. 845 00:31:22,975 --> 00:31:24,035 That's not the case. 846 00:31:24,414 --> 00:31:27,319 Don't withhold steroids in this scenario because the 847 00:31:27,319 --> 00:31:28,759 longer it takes for them to get the 848 00:31:28,759 --> 00:31:30,599 steroids, the more damage to their central nervous 849 00:31:30,599 --> 00:31:32,839 system is going on. I think this also 850 00:31:32,839 --> 00:31:34,380 made me a little more curious 851 00:31:34,839 --> 00:31:36,619 about how they were diagnosed 852 00:31:37,000 --> 00:31:39,000 because I did appreciate kind of the discussion 853 00:31:39,000 --> 00:31:41,134 of the MRI and the LP kind of 854 00:31:41,134 --> 00:31:42,654 depending on the picture that they give you 855 00:31:42,654 --> 00:31:44,494 and how certain it is. And I think 856 00:31:44,494 --> 00:31:46,734 for someone that was presenting saying, oh, I'm 857 00:31:46,734 --> 00:31:49,375 having another MS flare. My controller medications aren't 858 00:31:49,375 --> 00:31:51,855 working. This gave me a little more of 859 00:31:51,855 --> 00:31:53,615 an interest in saying, did you ever get 860 00:31:53,615 --> 00:31:55,519 an LP? Like, what was the MRI that 861 00:31:55,519 --> 00:31:57,440 they did? You know? And, like, have you 862 00:31:57,440 --> 00:31:59,759 seen a neurologist? Like, how deep, how complete 863 00:31:59,759 --> 00:32:01,519 was this workup? Because I think I'm gonna 864 00:32:01,519 --> 00:32:03,440 be more interested, especially in these patients that 865 00:32:03,440 --> 00:32:05,359 have some of these recurrent flares that don't 866 00:32:05,359 --> 00:32:07,585 seem like they're being controlled. I'm gonna go 867 00:32:07,585 --> 00:32:09,605 looking for more of these unusual, 868 00:32:09,984 --> 00:32:11,984 you know, different things on the differential by 869 00:32:11,984 --> 00:32:13,284 getting that LP done. 870 00:32:13,744 --> 00:32:15,664 Yeah. And when it comes to imaging, there 871 00:32:15,664 --> 00:32:18,464 are some fantastic pictures in the article about 872 00:32:18,464 --> 00:32:20,549 MRI imaging and how you can see these 873 00:32:20,549 --> 00:32:22,630 white lesions on MRI all over the brain 874 00:32:22,630 --> 00:32:24,309 and the spinal cord. Now it's important to 875 00:32:24,309 --> 00:32:26,470 keep in mind that the spinal cord is 876 00:32:26,470 --> 00:32:28,549 frequently involved because it's all part of the 877 00:32:28,549 --> 00:32:30,789 central nervous system. We typically think of this 878 00:32:30,789 --> 00:32:32,630 as being a brain phenomenon, but it's brain 879 00:32:32,630 --> 00:32:35,605 and spinal cord. Steroids, like I mentioned, are 880 00:32:35,664 --> 00:32:37,764 the mainstay of therapy, and we're talking 881 00:32:38,065 --> 00:32:38,565 large 882 00:32:38,944 --> 00:32:39,444 doses. 883 00:32:39,744 --> 00:32:41,605 And I found it interesting 884 00:32:41,984 --> 00:32:42,964 that there is 885 00:32:43,345 --> 00:32:44,005 a equipotence 886 00:32:44,625 --> 00:32:48,529 between oral and IV dosing of these massively 887 00:32:49,070 --> 00:32:52,450 large doses of steroids. So we're talking Solumetrol, 888 00:32:52,750 --> 00:32:53,650 a thousand milligrams 889 00:32:53,950 --> 00:32:55,410 IV, or prednisone, 890 00:32:56,110 --> 00:32:59,170 one thousand two hundred and fifty milligrams orally 891 00:32:59,710 --> 00:33:00,434 per day, 892 00:33:01,315 --> 00:33:03,075 which is just mind boggling to me that 893 00:33:03,075 --> 00:33:05,154 someone could take that much oral steroid and 894 00:33:05,154 --> 00:33:05,894 not immediately 895 00:33:06,434 --> 00:33:08,674 rot a hole in their gut. But, yes, 896 00:33:08,674 --> 00:33:12,055 it is proven to be safe, carefully administered, 897 00:33:12,195 --> 00:33:15,075 and that is the actual dosing necessary. So 898 00:33:15,075 --> 00:33:18,099 there is a oral route. It doesn't always 899 00:33:18,099 --> 00:33:20,259 have to be IV, which, again, I found 900 00:33:20,259 --> 00:33:22,180 interesting because it seems to me like at 901 00:33:22,180 --> 00:33:23,380 least the ones that showed up in the 902 00:33:23,380 --> 00:33:26,820 emergency department always needed IV access and IV 903 00:33:26,820 --> 00:33:28,660 Solu Medrol, and we're talking home health and 904 00:33:28,660 --> 00:33:30,259 setting this up as an outpatient, and it 905 00:33:30,259 --> 00:33:32,525 all took time and frequently resulted in an 906 00:33:32,525 --> 00:33:34,625 OBSTAY. We never really discussed 907 00:33:34,924 --> 00:33:36,924 oral options. You ever seen anybody take that 908 00:33:36,924 --> 00:33:37,664 much orally? 909 00:33:38,125 --> 00:33:39,964 I have not, but I think this is 910 00:33:39,964 --> 00:33:42,525 something that intrigues me as a you know, 911 00:33:42,525 --> 00:33:44,365 if someone is someone that's coming in more 912 00:33:44,365 --> 00:33:46,750 frequently. Or in this day and age, people 913 00:33:46,750 --> 00:33:48,029 are just so busy. I have the same 914 00:33:48,029 --> 00:33:50,509 discussion with antibiotics sometimes when using long acting 915 00:33:50,509 --> 00:33:51,009 antibiotics 916 00:33:51,470 --> 00:33:52,750 that people are just like, yeah. I just 917 00:33:52,829 --> 00:33:54,990 I can't be admitted right now. And I 918 00:33:54,990 --> 00:33:56,289 think I would entertain 919 00:33:57,069 --> 00:33:59,069 this as a treatment option for someone with 920 00:33:59,069 --> 00:34:01,694 well established MS that had, like, a, you 921 00:34:01,694 --> 00:34:04,174 know, relapsing remitting course and had tolerated oral 922 00:34:04,174 --> 00:34:06,095 steroids well before, and they were asking for 923 00:34:06,095 --> 00:34:07,615 it and saying, hey, I understand you wanna 924 00:34:07,615 --> 00:34:08,974 admit me to make sure we get this 925 00:34:08,974 --> 00:34:10,494 under control, but I just can't right now. 926 00:34:10,494 --> 00:34:11,775 I don't think based on this that I 927 00:34:11,775 --> 00:34:13,715 would hesitate to then provide it to them. 928 00:34:14,094 --> 00:34:16,679 Great point. There is also a role for 929 00:34:16,679 --> 00:34:17,179 baclofen 930 00:34:17,480 --> 00:34:20,380 in these patients. So baclofen, the muscle relaxants 931 00:34:20,599 --> 00:34:22,619 can help with the subsequent spasms 932 00:34:23,159 --> 00:34:25,179 and with symptomatic treatment. 933 00:34:25,800 --> 00:34:29,019 And it's usually provided in the way of 934 00:34:29,335 --> 00:34:32,454 oral medication or baclofen pumps, so people can 935 00:34:32,454 --> 00:34:33,275 have continuously 936 00:34:33,655 --> 00:34:34,715 infusing baclofen 937 00:34:35,094 --> 00:34:37,355 through an intrathecal pump, for example. 938 00:34:37,655 --> 00:34:40,295 And that can cause problems in and of 939 00:34:40,295 --> 00:34:42,074 itself with withdrawal 940 00:34:42,375 --> 00:34:44,639 if there's ever a problem with the pump. 941 00:34:44,880 --> 00:34:47,779 So much like we talked about with Parkinson's 942 00:34:48,079 --> 00:34:49,779 and people with deep brain stimulators, 943 00:34:50,159 --> 00:34:53,139 if you've got a device that you're requiring 944 00:34:53,519 --> 00:34:56,099 to be on and running twenty four seven 945 00:34:56,159 --> 00:34:58,019 and you undergo an MRI 946 00:34:58,400 --> 00:35:00,765 or have someone adjust this device, you need 947 00:35:00,765 --> 00:35:02,965 to make sure that the reason for their 948 00:35:02,965 --> 00:35:05,364 presentation isn't that this pump is now no 949 00:35:05,364 --> 00:35:07,945 longer working. And in the case of baclofen, 950 00:35:08,485 --> 00:35:09,224 the withdrawal 951 00:35:09,765 --> 00:35:11,545 becomes a life threatening 952 00:35:11,844 --> 00:35:12,344 withdrawal. 953 00:35:12,800 --> 00:35:16,320 We're talking things like intractable tetany and muscle 954 00:35:16,320 --> 00:35:18,179 spasms that affect respiration 955 00:35:18,559 --> 00:35:21,380 and lead people to become intubated and ventilated 956 00:35:21,519 --> 00:35:24,739 in order to prevent life threatening muscle contractions, 957 00:35:25,304 --> 00:35:26,764 typically treated with benzodiazepines 958 00:35:27,545 --> 00:35:29,704 in the hospital. So, again, not somebody you're 959 00:35:29,704 --> 00:35:31,864 going to send home until you're able to 960 00:35:31,864 --> 00:35:34,105 fix the problem and just something to be 961 00:35:34,105 --> 00:35:34,844 aware of. 962 00:35:35,224 --> 00:35:38,179 They can develop seizures. They can develop hyperthermia. 963 00:35:38,559 --> 00:35:40,800 They can go into rhabdo. So this can 964 00:35:40,800 --> 00:35:42,960 easily throw you off as a sepsis patient 965 00:35:42,960 --> 00:35:44,420 or, you know, encephalitis 966 00:35:44,719 --> 00:35:46,319 patient that you think is now febrile and 967 00:35:46,319 --> 00:35:48,000 seizing because of that. But I think as 968 00:35:48,000 --> 00:35:49,599 soon as you find out about that baclofen 969 00:35:49,599 --> 00:35:50,800 pump, you need to reach out to your 970 00:35:50,800 --> 00:35:53,594 neurosurgery colleagues, see who's filling it, see who's 971 00:35:53,594 --> 00:35:55,355 the one that's maintaining it, and can run 972 00:35:55,355 --> 00:35:56,795 a diagnostic on it to make sure it's 973 00:35:56,795 --> 00:35:58,795 working. And then see if they're interested in 974 00:35:58,795 --> 00:36:00,894 coming in and doing an LP to inject 975 00:36:01,034 --> 00:36:03,355 intrathecal baclofen while they're working out what's going 976 00:36:03,355 --> 00:36:04,889 on with their device, which I thought was 977 00:36:04,889 --> 00:36:06,730 one of the more elegant solutions to the 978 00:36:06,730 --> 00:36:08,889 problem that you could do the LP, get 979 00:36:08,889 --> 00:36:10,889 your diagnosis out, and then put your treatment 980 00:36:10,889 --> 00:36:12,730 in, and really just feel like you're a 981 00:36:12,730 --> 00:36:14,489 pretty hero doctor when you try to admit 982 00:36:14,489 --> 00:36:15,929 that one to the floor. Yeah. That is 983 00:36:15,929 --> 00:36:17,929 pretty amazing. Or the ICU, I guess. I 984 00:36:17,929 --> 00:36:19,849 guess that would even if you stabilized it, 985 00:36:19,849 --> 00:36:21,425 they'd probably still wanna put that in the 986 00:36:21,425 --> 00:36:23,505 ICU. I agree. I did mention earlier that 987 00:36:23,505 --> 00:36:25,824 optic neuritis is the most frequent presenting symptom, 988 00:36:25,824 --> 00:36:27,425 and there is evidence for a point of 989 00:36:27,425 --> 00:36:30,804 care ultrasound in diagnosing optic neuritis, specifically, 990 00:36:31,265 --> 00:36:33,605 in this small study that the author cited, 991 00:36:33,664 --> 00:36:36,130 that optic nerve diameter and optic nerve sheath 992 00:36:36,130 --> 00:36:38,769 diameter are significantly larger in the affected eye 993 00:36:38,769 --> 00:36:41,489 than the unaffected eye, and larger in patients 994 00:36:41,489 --> 00:36:44,050 with optic neuritis than in healthy kind of 995 00:36:44,050 --> 00:36:46,690 matched cohorts. And if you are adept at 996 00:36:46,690 --> 00:36:48,769 using the point of care ultrasound, and you're 997 00:36:48,769 --> 00:36:50,744 doing your ocular ultrasound, this is an easy 998 00:36:50,744 --> 00:36:53,065 measurement to make. I'm a big proponent of 999 00:36:53,065 --> 00:36:55,385 eyeball ultrasound for all kinds of things, including 1000 00:36:55,385 --> 00:36:57,784 retinal detachments, but that's going down the rabbit 1001 00:36:57,784 --> 00:36:59,464 hole for just a second. It's not that 1002 00:36:59,464 --> 00:36:59,964 hard 1003 00:37:00,264 --> 00:37:01,724 to make this measurement, 1004 00:37:02,025 --> 00:37:03,630 and, you know, it takes way too long 1005 00:37:03,630 --> 00:37:05,069 to do an MRI, and you could do 1006 00:37:05,069 --> 00:37:07,170 this at the bedside in, like, five minutes 1007 00:37:07,230 --> 00:37:08,369 and make this diagnosis. 1008 00:37:09,069 --> 00:37:10,989 We had a lens dislocation in the ER 1009 00:37:10,989 --> 00:37:12,589 the other day that was really cool. I'm 1010 00:37:12,589 --> 00:37:14,829 looking on the ultrasound. So I'll bet. Think 1011 00:37:14,829 --> 00:37:16,994 that the the benefit of this, if you 1012 00:37:16,994 --> 00:37:19,234 can see a significant difference in their optic 1013 00:37:19,234 --> 00:37:21,474 nerve, especially if you're getting pushback to admit 1014 00:37:21,474 --> 00:37:23,074 these people for their MRI and their workup, 1015 00:37:23,074 --> 00:37:24,594 I think it's another data point you can 1016 00:37:24,594 --> 00:37:27,315 use to encourage your upstairs colleagues that there's 1017 00:37:27,315 --> 00:37:29,219 something here to be worked up more. Yep. 1018 00:37:29,539 --> 00:37:31,400 Important things for us in the emergency department 1019 00:37:31,619 --> 00:37:34,359 are things like not missing infectious 1020 00:37:34,980 --> 00:37:35,480 causes 1021 00:37:35,780 --> 00:37:38,019 for a flare. You know, people with MS 1022 00:37:38,019 --> 00:37:40,579 can flare for multiple reasons, but infections are 1023 00:37:40,579 --> 00:37:42,434 one of them. And so we do wanna 1024 00:37:42,515 --> 00:37:44,775 check because they're frequently on immunosuppressive 1025 00:37:45,315 --> 00:37:48,215 therapy, much like our patients with myasthenia gravis. 1026 00:37:48,275 --> 00:37:50,135 So you don't wanna miss an infection 1027 00:37:50,434 --> 00:37:52,215 if that's what's causing their flare. 1028 00:37:52,515 --> 00:37:54,449 And keep in mind that people can get 1029 00:37:54,690 --> 00:37:57,409 flares or pseudo flares triggered by things like 1030 00:37:57,409 --> 00:37:59,570 fever and even heat. Now I found this 1031 00:37:59,570 --> 00:38:01,969 pretty interesting that, you know, even a viral 1032 00:38:01,969 --> 00:38:03,969 infection causing a little bit of fever can 1033 00:38:03,969 --> 00:38:06,150 trigger a pseudo flare, meaning 1034 00:38:06,449 --> 00:38:09,010 that their symptoms are just acutely worse because 1035 00:38:09,010 --> 00:38:11,255 of the fever, and that control of fever 1036 00:38:11,255 --> 00:38:12,875 can actually help in that scenario. 1037 00:38:13,494 --> 00:38:15,355 Much like the other two diseases, 1038 00:38:15,815 --> 00:38:17,894 lots of things to know and a ton 1039 00:38:17,894 --> 00:38:20,454 of information in this article that I thought 1040 00:38:20,454 --> 00:38:22,215 the authors did a really good job of 1041 00:38:22,215 --> 00:38:22,715 presenting. 1042 00:38:23,409 --> 00:38:25,650 Alright. And on that note, let's do a 1043 00:38:25,650 --> 00:38:28,929 couple more trivia questions for you, sir. When 1044 00:38:28,929 --> 00:38:32,130 it comes to brain MRI findings, typical of 1045 00:38:32,130 --> 00:38:35,190 MS, what do white matter lesions 1046 00:38:35,650 --> 00:38:36,869 represent? A, 1047 00:38:37,514 --> 00:38:38,014 hemorrhage, 1048 00:38:38,714 --> 00:38:39,694 b, calcifications, 1049 00:38:41,114 --> 00:38:42,414 c, demyelinating 1050 00:38:43,114 --> 00:38:43,614 plaques, 1051 00:38:44,474 --> 00:38:48,014 d, infarcts from emboli, or, e, tumor metastases. 1052 00:38:49,760 --> 00:38:51,519 Think in the the MS patient this is 1053 00:38:51,519 --> 00:38:54,000 c. It is. C is demyelinating plaques. That 1054 00:38:54,000 --> 00:38:56,900 is indeed the typical appearance of the multiple 1055 00:38:57,119 --> 00:38:57,619 sclerosis 1056 00:38:57,920 --> 00:38:59,059 white matter lesion. 1057 00:38:59,760 --> 00:39:01,619 Alright. One more on multiple sclerosis. 1058 00:39:01,925 --> 00:39:03,605 Which of the following is the most common 1059 00:39:03,605 --> 00:39:06,664 initial presenting symptom in patients with multiple sclerosis? 1060 00:39:06,965 --> 00:39:10,585 A, bulbar weakness, which is facial muscle weakness, 1061 00:39:10,885 --> 00:39:12,905 double vision dysarthria or dysphagia, 1062 00:39:13,844 --> 00:39:15,864 double vision with neck flexion, 1063 00:39:17,210 --> 00:39:21,069 Lhermitte sign, which is that electrical shock sensation 1064 00:39:21,449 --> 00:39:23,869 shooting down the spine caused by neck flexion, 1065 00:39:24,809 --> 00:39:25,710 optic neuritis, 1066 00:39:26,409 --> 00:39:27,549 or Yudhoeff 1067 00:39:28,010 --> 00:39:30,349 phenomenon, which is transient worsening 1068 00:39:30,650 --> 00:39:31,549 of previous 1069 00:39:31,849 --> 00:39:32,670 MS symptoms 1070 00:39:33,105 --> 00:39:35,505 as a result of increased core body temperature. 1071 00:39:35,505 --> 00:39:36,945 That's the pseudo Well, it's a cool name. 1072 00:39:36,945 --> 00:39:38,625 But I'm gonna go with, I think 1073 00:39:39,264 --> 00:39:41,664 wait. Which one was Lermi? Lermi was d? 1074 00:39:41,744 --> 00:39:44,144 Was the oh, c. Lermi was c electric 1075 00:39:44,144 --> 00:39:46,085 shock. I want d d was optic neuritis. 1076 00:39:46,550 --> 00:39:48,150 Optic neuritis is where I'm going. Yes, sir. 1077 00:39:48,150 --> 00:39:50,070 Finally. That's right. It accounts for twenty two 1078 00:39:50,070 --> 00:39:52,489 percent of first time presentations is optic neuritis. 1079 00:39:52,550 --> 00:39:53,829 So that's when you pull out your point 1080 00:39:53,829 --> 00:39:54,730 of care ultrasound. 1081 00:39:55,030 --> 00:39:57,349 Alright, ladies and gentlemen. Well, we covered lots 1082 00:39:57,349 --> 00:40:00,125 of information, but there is a ton more. 1083 00:40:00,125 --> 00:40:02,364 So if you have access, I can't recommend 1084 00:40:02,364 --> 00:40:04,385 enough that you go and read this article 1085 00:40:04,525 --> 00:40:07,105 about Parkinson's, myasthenia gravis, and multiple sclerosis, 1086 00:40:07,484 --> 00:40:10,284 and digest and ingest all of the information 1087 00:40:10,284 --> 00:40:11,984 here and get your four hours of CME. 1088 00:40:12,079 --> 00:40:14,639 It's really quite the volume of information on 1089 00:40:14,639 --> 00:40:16,179 all three of these disease processes 1090 00:40:16,559 --> 00:40:17,059 specific 1091 00:40:17,360 --> 00:40:19,840 to the ED. Now we didn't mention in 1092 00:40:19,840 --> 00:40:22,880 any of these really pre hospital care because 1093 00:40:22,880 --> 00:40:25,619 it's challenging enough to make and treat these 1094 00:40:25,920 --> 00:40:26,420 diagnoses 1095 00:40:26,855 --> 00:40:29,255 in the emergency department in the pre hospital 1096 00:40:29,255 --> 00:40:31,994 setting. It's often focused on rapid assessment, 1097 00:40:32,295 --> 00:40:34,534 knowledge of what medications they're currently on, and 1098 00:40:34,534 --> 00:40:36,214 bringing those with them, especially if they have 1099 00:40:36,214 --> 00:40:38,534 Parkinson's so they don't miss doses. If they 1100 00:40:38,534 --> 00:40:41,219 have assistive devices, bringing those, and then getting 1101 00:40:41,219 --> 00:40:43,059 that history from someone on the scene who 1102 00:40:43,059 --> 00:40:45,059 can help, all of those are critical things 1103 00:40:45,059 --> 00:40:46,739 to do in the pre hospital setting, and 1104 00:40:46,739 --> 00:40:48,659 we didn't dive into that much today. But 1105 00:40:48,659 --> 00:40:50,579 there is a good section on each of 1106 00:40:50,579 --> 00:40:52,119 those disease processes 1107 00:40:52,500 --> 00:40:54,659 for the pre hospital setting, and lots of 1108 00:40:54,659 --> 00:40:58,594 pictures. MRI, ultrasound. It's a fantastic issue. I 1109 00:40:58,594 --> 00:41:00,914 highly recommend you go read it. I completely 1110 00:41:00,914 --> 00:41:03,155 agree. These are three diseases that if you 1111 00:41:03,155 --> 00:41:05,474 just take the time to, like, learn the 1112 00:41:05,474 --> 00:41:07,315 history and the background of them, it'll give 1113 00:41:07,315 --> 00:41:09,235 you just a profound appreciation for the progress 1114 00:41:09,235 --> 00:41:11,170 that we're making. I have hope for the 1115 00:41:11,170 --> 00:41:14,130 future, and I am just always interested in, 1116 00:41:14,130 --> 00:41:15,730 you know, the casual way that I get 1117 00:41:15,730 --> 00:41:18,210 to throw miracles around in tiny pill bottles 1118 00:41:18,210 --> 00:41:19,809 in this job. And I try to maintain 1119 00:41:19,809 --> 00:41:21,969 a healthy respect for it. There it is, 1120 00:41:21,969 --> 00:41:24,485 ladies and gentlemen. Doctor t r Eckler, ten 1121 00:41:24,485 --> 00:41:26,565 out of 10 today. Got all the trivia 1122 00:41:26,565 --> 00:41:28,724 questions right. Hey. That's a giant round of 1123 00:41:28,724 --> 00:41:30,325 applause for him right there, ladies and gentlemen. 1124 00:41:30,325 --> 00:41:31,605 I think we'll bring him back for another 1125 00:41:31,605 --> 00:41:32,105 episode. 1126 00:41:32,644 --> 00:41:33,785 One more One 1127 00:41:34,244 --> 00:41:35,945 more time. Just one more. 1128 00:41:36,829 --> 00:41:38,590 And that's a wrap. Thanks for joining us 1129 00:41:38,590 --> 00:41:40,210 for this episode of Amplify. 1130 00:41:40,510 --> 00:41:42,909 I hope you found it informative, and I 1131 00:41:42,909 --> 00:41:45,390 wanna remind you that ebmedicine.net 1132 00:41:45,390 --> 00:41:47,550 is your one stop shop for all of 1133 00:41:47,550 --> 00:41:50,224 your CME needs, whether that be for emergency 1134 00:41:50,224 --> 00:41:52,945 medicine or urgent care medicine. There are three 1135 00:41:52,945 --> 00:41:55,905 journals. There's tons of CME. There's lots of 1136 00:41:55,905 --> 00:41:58,785 courses. There's so many clinical pathways, all this 1137 00:41:58,785 --> 00:42:00,344 information at your fingertips 1138 00:42:00,644 --> 00:42:02,664 at dbmedicine.net. 1139 00:42:02,804 --> 00:42:04,884 Until next time, everyone. I'm your host, Sam 1140 00:42:04,884 --> 00:42:05,384 Ashu. 1141 00:42:05,684 --> 00:42:06,344 Be safe.