Grand Rounds Recap 8.14.19

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PEDIATRIC ENT EMERGENCIES WITH DR. SMITH

Ears

  • Acute Otitis Media (AOM)

    • Caused by obstruction of the eustachian tube - children are more susceptible because this is more horizontal and smaller in diameter

    • Physical exam findings: bulging tympanic membrane (TM), new onset otorrhea, intense TM erythema with effusion (if there is no effusion this is not AOM)

    • Ear pain does not equal AOM

    • Antibiotic selection

      First line: High dose amoxicillin

      Second Line: Amoxicillin-clavulonic acid

      Third Line: IM ceftriaxone or PO cefdinir

  • Complications of AOM

    • Mastoiditis, subperiostial abscess, facial nerve paralysis, meningitis, intracranial abscess, venous thrombosis

    • Mastoiditis

      • Presents with post-auricular edema and erythema

      • Diagnosis is confirmed with CT scan

      • These patients need IV antibiotics, emergent myringotomy, incision and drainage, and possibly a mastoidectomy

    • Meningitis - the treatment is the same as standard meningitis, but these patients will also need an urgent myringotomy and audiogram when stable

      • 10-20% of patients have sensorineural hearing loss due to hardening of the cochlea that requires a cochlear implant

  • Auricular Hematoma

    • This needs to be evacuated by either needle aspiration or incision and drainage to prevent the development of a cauliflower ear

    • Use an 18 or 20 gauge needle to aspirate the dependent area of the hematoma and apply a sutured bolster dressing with xeroform gauze - do not use silk or braided suture to prevent infection.

      • Children may not tolerate this, so consider using a head wrap

Nose

  • Acute sinusitis

    • Imaging is not indicated in uncomplicated sinusitis

    • Symptoms need to be present for 10 days before treatment as this is often a viral infection with no role for antibiotics

    • Imaging is indicated if complications develop

      • Preseptal cellulitis

      • Orbital cellulitis

      • Supberiosteal abscess

      • Orbital abscess

      • Cavernous sinus thrombosis

    • Anything complications other than preseptal cellulitis need IV antibiotics, nasal saline irrigation, decongestants, and ENT/Opthalmology consults

  • Nasal foreign body

    • Always suspect this with unilateral rhinorrhea

    • Attempt to remove as gently as possible - if unable, call ENT for removal

  • Septal hematoma

    • This needs to be drained emergently

    • Use an 18 or 20 gauge needle for aspiration,

    • Apply oxymetazoline and local anesthesia on cotton ball and insert this in the nostril

    • If there is a suspected facial fracture other than an isolated nasal bone fracture, obtain a CT scan of the maxillofacial bones

    • Patients with isolated nasal fractures do not need imaging, but should be referred to ENT in 5 days

    • If a CSF leak is suspected, consider beta-2-transferrin testing of the nasal fluid.

      • These patients need to be admitted and treated with antibiotics

  • Epistaxis

    • Recurrent epistaxis in an adolescent male - keep juvenile nasopharyngeal angiofibroma on your differential

    • Apply oxymetazoline and pressure first, then topical hemostatic agents, and finally packing as a last resort

      • Merocel nasal tampons are anecdotally more comfortable than balloon tamponade devices (such as the rapid rhino)

        • Antibiotics are still recommended, although multiple studies show no real benefit due to the extremely low rate of toxic shock syndrome

Throat

  • Mononucleosis

    • Presents with high fevers, bilateral cervical lymphadenopathy, fatigue, and bilateral tonsillar exudates

    • Monospot can be falsely negative - obtain EBV IgG/IgM titers if you have a high clinical suspicion

  • Peritonsillar abscess

    • Trismus is a very common physical exam finding

    • Drain the area with needle aspiration in the superior, middle, and inferior poles

  • Retropharyngeal abscess

    • Seen as widening of retropharyngeal space on a lateral neck film

    • These patients need to be admitted for IV antibiotics and observation to determine if operative drainage is needed

Airway

  • Stridor

    • The most common cause of stridor in children is laryngomalacia

    • The second most common cause is vocal fold paralysis - this is usually from recurrent laryngeal nerve injury during cardiac surgery

  • Subglottic stenosis - this can be congenital or acquired from multiple intubations

  • Foreign body

    • Persistent cough, stridor, wheezing, or recurrent pneumonia

    • The right lung is more frequently affected

    • Airway foreign bodies are most common in the 1-3 year age range

    • Laryngeal foreign bodies have an extremely high mortality rate due to complete airway obstruction and need to be removed emergently

  • Epiglottitis

    • Most commonly due to Haemophilus influenzae

    • The incidence of this is increasing with decreasing vaccination rates

    • If you have a high clinical suspicion, the patient needs an endoscopic examination in the operating room with preparation for intubation

  • Bacterial tracheitis

    • Fever, cough, inspiratory stridor with pain to palpation over the anterior neck

    • These patients need to be intubated and have a bronchoscopy, as well as IV antibiotics

TAMING THE SRU: toxic seizure WITH DR. GLEIMER

Anticholinergic Toxicity

  • Presentation

    • Anhidrosis, hyperthermia, mydriasis, delirium, cutaneous vasodilation

    • Cardiovascular abnormalities: tachycardia, QRS widening

    • Neurologic abnormalities: seizures

  • Treatment

    • Benzodiazepenes remain first line therapy

    • Hyperthermic patients should be actively cooled and intubated for paralysis if they remain hyperthermic

    • Sodium bicarbonate should be administered if the QRS complex is widened

    • Physostigmine

      • This is an acetylcholinesterase inhibitor

      • Dosage: 0.5-2 mg IV over 5 minutes

      • Be cautious with administration, as this medication lowers the seizure threshold and can cause asystole if the patient overdosed on a tricyclic antidepressant

Ingestion-induced seizures

  • Ingestion is the cause of 9% of all seizures

  • Common medications that are associated with seizures

    • Antidepressants such as tricyclic antidepressants, bupropion, and venlafaxine

    • Stimulants such as cocaine, amphetamine, MDMA

    • Other common medications including diphenhydramine, tramadol, and isoniazid

  • Treatment

    • Benzodiazepenes are first line

    • Second line are barbituates followed by propofol

    • There is no role for phenytoin, and other AEDs have not been validated

    • Remember to administer pyrodoxine if there is any history of isoniazid ingestion

CPC: disseminated gonorrhea WITH DRS. BERGER AND BAEZ

 Case Presentation

  • The patient is a female in her 30’s with a past medical history of diabetes, anxiety, and hepatitis C presenting with left sided body pain that started 3 hours ago and woke her from sleep. The pain began in her joints on the left side and is associated with a severe headache. She is currently not taking any medications. She is homeless and endorses marijuana and alcohol use, and denies IVDA.

  • On exam she is tachycardic and appears uncomfortable, tachypneic, with tenderness in the left upper and left lower abdomen. She is diffusely tender along the entire spine as well as the left hip, right knee, and bilateral wrists. Her neurologic exam is normal. Her laboratory studies are unremarkable with the exception of a mild transaminitis, macroscopic urinalysis with both hematuria and proteinuria, with only 1 RBC and no pyuria on microscopic analysis, and slightly elevated inflammatory markers. Her EKG is non-ischemic and her CXR is normal. Her pregnancy test is negative. She was given fluids, NSAIDs, and morphine without improvement of her symptoms. She later reports that she is on her menstrual period and it is heavier than normal. CT of the chest, abdomen, and pelvis is normal. She is now febrile to 101, and prior to admission, a test is ordered to clinch the diagnosis.

The Differential (Top 5 bolded)

  • Neurologic

    • Stroke, intracranial mass, seizure, multiple sclerosis

  • Vascular

    • Aortic dissection, vasculitis, venous thromboembolism, arterial thrombosis/embolism

  • Spine

    • Brown-sequard, spinal stroke, transverse myelitis, epidural abscess

  • Infectious

    • Bacteremia

      • Disseminated gonorrhea, toxic shock syndrome, rheumatic fever, tuberculosis

    • Septic arthritis

    • Viremia

      • EBV, Hepatitis B or C, HIV, parvovirus, dengue, chikungunya

    • Spirochetemia

      • Syphilis, lyme disease

    • Bacterial endocarditis

  • Musculoskeletal

    • Multiple myeloma, paget’s disease, gout, pseudogout

    • Compartment syndrome, rhabdomyolysis

    • Gravity dependent pain from prolonged left lateral decubitus positioning

  • Autoimmune

    • Reactive arthritis, lupus, rheumatoid arthritis

Test and Diagnosis

  • Blood cultures - disseminated gonococcal infection

Disseminated Gonococcal Infection

  • Epidemiology

    • There are over 800,000 reported cases of gonnorhea in the US with only a small proportion developing disseminated disease

    • This is more common in females less than 40 years old with no recent symptomatic genital infection who are menstruating

    • 13% of all patients have a complement deficiency and are prone to recurrent infections

  • Presentation

    • Tenosynovitis, polyarthralgia, and vesiculo-pustular lesions are present in 75-85% of patients

    • Only 60% of patients present with fever

  • Diagnosis

    • Blood cultures are only positive in 4-70% of patients

    • Mucosal swabs are much more sensitive - positive in 86% of patients

    • Synovial fluid has less than 50% sensitivity

  • Treatment

    • 1-2 grams of ceftriaxone daily with a one time dose of 1 gram of azithromycin for concomitant chlamydia coverage

R1 CLINICAL DIAGNOSTICS: Toxic ALCOHOLs WITH DRS. KIMMEL AND OWENS

Please see Dr. Kimmel’s fantastic asynchronous post here for more detailed information

Calculating the osmolar gap

  • 2 x Na + Glu/18 + BUN/2.8 + EtOH/4.6 to determine the expected osmolality

  • Order a measured serum osmolality and subtract your calculated osmolality - this is your osmolar gap

  • Patients who present acutely following an ingestion will develop an osmolar gap before an anion gap

  • As your osmolar gap is closing, your anion gap is rising in a toxic alcohol ingestion

Case 1: Methanol toxicity

  • Toxicity is due to formic acid

  • Treatment: fomepizole or IV ethanol, leucovorin/IV folate, or ultimately hemodialysis

Case 2: Ethylene glycol toxicity

  • Toxicity is due to glycolic acid and oxalic acid which crystalizes and deposits in the kidney and causes renal failure

  • Sodium fluorescein is intentionally added to antifreeze so that body fluids will fluoresce under a woods lamp, however this is neither sensitive nor specific

  • Treatment: fomepizole, pyridoxine, and hemodialysis

Case 3: Propylene glycol toxicity

  • Used to dilute a number of medications, including phenytoin, lorazepam, and phenobarbital

  • Propylene glycol is metabolized to lactate and causes a profound lactic acidemia

  • Treatment: discontinue the offending agent, administer sodium bicarbonate, and ultimately hemodialysis

R4 CASE FOLLOW UP WITH DR. MURPHY-CREWS

The patient is a female in her 60s with a past medical history of a clipped cerebral aneurysm and a second unsecured aneurysm who presents with a sudden onset thunderclap headache 2 hours prior to presentation. Her vitals are normal and she appears uncomfortable but has a normal neurologic exam. Non-contrast head CT is read as normal, although there is significant artifact from the previous clip.

Headaches

  • 5th most common chief complaint in the emergency department

  • Subarachnoid hemorrhage accounts for less than 1% of all headaches

Subarachnoid Hemorrhage (SAH)

  • 85% of subarachnoid hemorrhages are aneurysmal and have poor outcomes, even if diagnosed and treated early

  • Patients with non-aneurysmal bleeding (perimesencephalic subarachnoid hemorrhage) almost always have good outcomes

  • The culture in emergency medicine is a 0-2% miss rate for subarachnoid hemorrhage upon discharge, and many physicians will perform a lumbar puncture if a head CT is normal

    • It is important to note that LPs are not a benign procedure, and can result in false positive test results

  • Modern CT technology has advanced significantly

    • Perry et. all (2011) - this was a prospective cohort study that showed a CT scan was 93% sensitive in all patients who presented with a headache, and 100% sensitive if obtained within 6 hours of symptom onset

  • Ottawa SAH Rule

    • This is a derived and validated decision tool based on 5 historic features and 1 physical exam finding

      • Age < 40, no witnessed LOC, no onset during exertion, no thunderclap component, no subjective neck pain or stiffness, and no limited neck flexion on exam

    • If all criteria are met, CT scan is not necessary as this is 100% sensitive in ruling out SAH

  • CT angiogram for exclusion of aneurysm as an alternative to lumbar puncture

    • CTA misses alternative diagnoses such as meningitis

    • 3% of patients will have incidental benign aneurysms (false positives)

    • ACEP recommends shared decision making with the patient and that this is a reasonable alternative to lumbar puncture

Case Conclusion

 PEDIATRIC GI BLEEDING WITH DR. BENSMAN

Anal fissures are the most common cause of bloody stool in all ages, and occur most frequently at the 12 or 6 o’clock position

Neonatal and Infants

  • Emergent conditions include congenital coagulopathies, necrotizing enterocolitis, and malrotation with volvulus

  • Infants who are breastfeeding can appear to have GI bleeding from swallowed maternal blood, so always be sure to ask mom about any bleeding

  • Also remember to ask about newborn screen results for congenital coagulopathy

  • Important things to look for on physical exam are abdominal distention/tenderness as well as the patient’s mental status

  • GI bleeding imposters - circumcision bleeding, neonatal withdrawal bleeding/pseudomenstruation, hematuria, uric acid crystals, and swallowed maternal blood

  • Hemorrhagic disease of the newborn

    • All infants are born with a relative Vitamin K deficiency

    • Bleeding is most often intracranial but can present with GI bleeding

    • If suspicious (such as a history of home birth), treat with IV vitamin K and FFP in critically ill patients

Young Children

  • Emergent conditions include intussusception, meckel diverticululm, and vascular lesions

  • Imposters:

    • Red stool: antibiotics (cefdinir, rifampin, cherry flavoring), red gelatin, candies, and fruits

    • Black stool: bismuth, iron, charcoal, chocolate, blueberries, dark green foods, and epistaxis with swallowed blood

  • Inflammatory bowel disease (IBD)

    • 1/4 of IBD presents before age 20, often atypically

    • Children are more likely to have upper GI symptoms and extraintestinal manifestations of IBD

Adolescents

  • Emergent conditions are similar to adults and include varices, peptic ulcer disease, ulcerative colitis, and crohn’s disease

  • Causes of pediatric portal hypertension

    • Prehepatic: portal vein obstruction, stenosis, and compression

    • Intrahepatic: congenital hepatic fibrosis, granulomatous disease

    • Posthepatic: constrictive pericarditis, hepatic vein thrombosis, congenital heart disease, congenital IVC malformations

Upper GI bleeding

  • Management is similar to adult patients

    • The threshold for transfusion is a hemoglobin of 8 g/dL

    • Transfuse 10-15 mL/kg to increase hemoglobin 1 g/dL

    • Proton pump inhibitor dosing: bolus 1 mg/kg

    • Octreotide dosing: bolus 1 mcg/kg, infusion at 1-3 mcg/kg/hr

Common etiologies that do not need to be transferred

  • Infants: anal fissure, milk protein allergy

  • Older children: hemorrhoids, enteric infections, HSP

  • Adolescents: new IBD, mallory weiss tears

Potentially emergent causes that should be transferred

  • Neonates: NEC, volvulus, coagulopathy

  • Intussusception, Meckel diverticulum, HUS

  • Varices, Ulcers

Critical bleeds

  • These are often due to varices or ulcers

  • Treat these similar to adults - manage the patient’s ABCs and support their hemodynamics with blood products while arranging transfer for endoscopic evaluation and intervention