Grand Rounds Recap 12.11.19

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R4 Case Follow Up with Dr. Humphries

Traumatic Cardiac Arrest

  • The survival rate for blunt traumatic arrest is between 6-8% (higher than previously believed)

  • Mechanical vs manual chest compressions

    • Most current literature shows that there are no outcome benefits with mechanical CPR vs manual compressions

  • Chest compressions in traumatic arrest

    • No human data exists to support CPR in traumatic arrest

    • Animal data (pigs) - the only pigs that achieved ROSC received whole blood or whole blood + CPR (no ROSC in CPR only, saline only, or saline + CPR)

  • Reversible causes of death in trauma: Hypovolemia, hypoxia, cardiac tamponade, and tension pneumothorax

    • CPR makes all of the interventions to reverse these causes of death more difficult

  • Epinephrine in traumatic arrest

    • Several studies show that the use of epinephrine is associated with decreased survival in trauma patients

    • Some data shows increased rates of pre-hospital ROSC with no increased 30 day survival

    • Bottom line: epinephrine does not have a role in traumatic cardiac arrest, especially suspected to be due to hemorrhage/exsanguination

  • Volume resuscitation

    • Pre-hospital plasma administration improves survival

    • If blood products are available, use them instead of crystalloid

  • Chest decompression

    • Needle decompression: you are more likely to enter the pleural space if you use the anterior mid-axillary line at the 4th/5th intercostal space as opposed to the 2nd intercostal space in the mid-clavicular line

    • Bottom line: needle decompress the patient with a pulse, open/finger thoracostomy for the patient who has arrested

  • Protocol for blunt traumatic cardiac arrest

    • Control hemorrhage with tourniquets and a pelvic binder

    • Give volume - blood products are preferred if available

    • Bilateral finger thoracostomies

    • Pericardiocentesis or cardiac ultrasound to evaluate for tamponade

    • CPR only after the above interventions have been performed

    • No epinephrine unless you are concerned about an alternative cause of arrest, such as a medical arrest leading to the trauma

  • Traumatic intracranial aneurysm/pseudoaneurysm following closed head injury

    • Very little data exists on the incidence of this injury

    • Most commonly occurs 2-3 weeks post injury

    • Rupture rate is ~19%

EM-Neuro Combined Conference: Approach to Encephalopathy with Dr. Neel

 Encephalopathy - “disorder of brain function”

  • Alterations in level of consciousness

    • Delirium or coma imply an altered level of consciousness

    • Encephalopathy does not necessarily cause an alteration in level of consciousness

    • Dementia by definition does not cause a change to the level of consciousness

      • Two types of cognitive function need to be impaired, not just memory

  • Time frame is key to forming a differential

  • Collateral information is also key if available, including concurrent medical conditions and medications

Acute encephalopathy

  • Delirium is the most common cause

    • Metabolic

    • Toxicologic or medication induced

      • Hepatic encephalopathy/hyperammonemia

      • Uremic encephalopathy

      • Steroid responsive encephalopathy associated with thyroiditis

    • Infectious

      • Can be both systemic or primary CNS infection

      • Always ask about travel history, sick contacts, animal exposures, etc.

    • Structural

      • Subdural hematoma, subarachnoid hemorrhage

    • Cerebrovascular

      • Acute ischemic stroke

      • Recrudescence of previous stroke

    • Seizure

    • Autoimmune encephalitis

      • Presents with primarily psychiatric symptoms, especially if the patient does not have a previous psychiatric history

Acute on chronic encephalopathy

  • Acute delirium on a chronic cognitive change

  • Malignancy

  • Creutzfeldt-Jakob Disease

Chronic encephalopathy

  • Dementia,

  • Anoxic changes after brain injury

  • Encephalitis

  • Korsakoff syndrome

Approach to the confused patient

  • Check vital signs and obtain a fingerstick blood glucose

  • Perform a general physical exam and full neurologic exam

  • Lab data

    • Things we often forget - LFTs with ammonia, TSH, B12, UDS, and medication levels for any medications that can be checked - AEDs, digoxin, lithium

  • CT of the head without contrast

  • If all of the above are negative, consider an EEG

  • If there is still no answer, consider an LP but if possible, obtain an MRI (with and without contrast) prior to LP if no concern for infection

    • If an LP is performed prior to MRI, it can cause imaging changes that are similar to meningitis

    • If you have a high suspicion for infection, do not delay antibiotic administration or LP to obtain imaging

    • Send CSF for standard infectious labs, make sure to collect an extra 4-5 mL of CSF for additional testing such as IGG index, oligoclonal bands, HSV antigen, and cryptococcal antigen

  • Administer 100 mg of IV thiamine

  • Secondary labs: serum immunofixation, FTA for syphilis (not RPR), HIV, thyroid peroxidase and thyroglobulin antibodies (these are associated with autoimmune encephalopathy), thiamine level, CK (this can be found in NMS), and MMA

  • Tertiary labs: heavy metals (especially lead, mercury), quantiferon gold, paraneoplastic antibodies, NMDA antibodies, fungal studies

Global Health Grand Rounds with Dr. Bryant

Pediatric Nephrotic Syndrome

  • Present with peripheral edema, fever, fatigue, abdominal pain and poor appetite

  • Laboratory abnormalities

    • Urinalysis - massive proteinuria (ideally followed by a 24 hour collection)

    • LFTs - hypoalbuminemia

    • Lipid panel - hyperlipidemia

  • Primary nephrotic syndrome

    • Minimal change disease (most common cause in the US)

    • FSGS

    • Membranous nephropathy

    • C3 glomerulonephritis

    • IgA nephropathy

    • Postinfectious glomerulonephritis

  • Secondary nephrotic syndrome

    • SLE, HSP, syphilis, malaria, HIV, drug poisoning (e.g. Mercury), diabetes, malignancy

  • Things to worry about as an Emergency Physician in a patient with nephrotic syndrome

    • Thrombosis

    • Immune compromise

    • Acute renal failure

  • Hyponatremic seizure

    • Treat with 4 mL/kg of 3% hypertonic saline

    • Sodium bicarbonate can also be used at a dose of 2 mL/kg

Mercury poisoning

  • Can be seen in gold smelters and miners

    • Mercury is the easiest and cheapest way to extract gold from the earth

    • In the process, mercury is vaporized off of the gold and inhaled

  • Mercury exists in 3 forms: elemental, inorganic, and organic

  • Elemental poisoning

    • Metal fume fever

      • Influenza like illness

    • Pulmonary manifestations

    • Chronic classic triad: tremor, mouth sores, and emotional lability

  • Inorganic poisoning

    • Primarily occurs following oral ingestion and presents with GI symptoms and can cause renal failure

  • Organic poisoning

    • Presents with neurologic symptoms and can cause hematologic derangements

    • Highly fetotoxic in pregnant patients

  • Patients can be chelated with succimer, dimercaprol, or penicillamine

    • Chelation often does not reverse neurologic symptoms

R1 Clinical Knowledge: Acute Leukemia with Dr. Ramsey

Hyperleukocytosis

  • WBC greater than 100,000

  • Can result in leukostasis

    • Most commonly seen in AML

    • Causes end organ damage and patients present with respiratory distress, neurologic symptoms, or renal failure

  • Treatment

    • Aggressive IVF and broad spectrum antibiotics

    • Early induction chemotherapy

      • Hydroxyurea can be given in the ED to help lower the WBC

    • Leukapheresis

      • Indicated in AML with a WBC count > 100,000

Tumor Lysis Syndrome

  • Results from cellular lysis and spilling of intracellular contents into the serum

  • Most commonly seen in ALL - up to 20% of patients will develop this after induction chemotherapy

  • Electrolyte abnormalities

    • Hyperkalemia

    • Hyperphosphatemia

    • Hypocalcemia

    • Increased serum uric acid

  • Cairo-Bishop Criteria

    • Laboratory based score based on electrolyte abnormalities

    • A score greater than 2 is used to diagnose tumor lysis syndrome

  • Treatment

    • IV Fluids

    • Dialysis for refractory hyperkalemia and anuric renal failure

    • Allopurinol inhibits the production of additional uric acid

    • Rasburicase increases uric acid clearance

Disseminated Intravascular Coagulation

  • Thrombo-hemorrhagic complication most commonly seen in APML

  • Can present with petechial hemorrhage and bleeding around IV sites

    • Serious complications that can result in death include GI bleeding and intracranial hemorrhage

  • Laboratory findings

    • Thrombocytopenia

    • Low fibrinogen

    • Elevated D-dimer

  • Treatment

    • Replete coagulation factors as needed

    • All trans retinoic acid (ATRA) improves mortality in APML

      • Patients may develop respiratory distress requiring airway intervention after administration

Neutropenic Fever

  • Defined as a single oral temperature of 38.3 or sustained oral temperature of 38 for more than 1 hour

  • Neutropenia - defined as an absolute neutrophil count < 1500

  • Early administration of antibiotics within 2 hours of presentation is key

    • Review prior cultures if available when selecting antibiotics

  • MASCC risk index score

    • Scores > 21 indicate low risk patients who may be candidates for outpatient management

    • If the patient’s ANC is > 1000 and it has been > 14 days since their last chemotherapy treatment, they can potentially be discharged after consultation with oncology on an oral fluoroquinolone and beta-lactam

Pediatrics SimulatioN

Pertussis

  • Phases

    • Catarrhal phase - first 1-2 weeks, non-specific viral sypmtoms

    • Paroxysmal phase - begins during the 2nd week of illness, presenting with severe, vigorous coughs during single expiration

      • Antibiotics do not shorten the course of the paroxysmal phase

    • Convalescent phase - gradual improvement over 1-2 weeks but may take months to completely resolve

  • Concerning features - hypoxia, apnea for greater than 15-20 seconds

  • Diagnostics

    • CXR

    • CBC

      • Pertussis may cause a profound lymphocytic leukocytosis (malignant pertussis)

        • Absolute white count > 48 or increase of 30% from baseline are indications for exchange transfusion

  • Treatment - IVF, supplemental oxygen as needed, macrolide antibiotics (azithromycin, erythromycin)

    • Contacts should be tested and the health department should be contacted if you have a high clinical suspicion for pertussis

Febrile Seizures

  • Occur between the ages of 6 months and 6 years

  • Simple

    • Generalized tonic-clonic seizure

    • Seizure + post-ictal period lasts less than 15 minutes

    • Only 1 seizure in 24 hours

  • Complex

    • Focal seizure

    • Seizure + post-ictal period lasts longer than 15 minutes

    • Multiple seizures in 24 hour period

  • Occurs in 2-4% of children and 30-40% of patients will have another seizure

    • Scheduled antipyretics may help prevent seizure recurrence during the presenting course of illness

  • 2% of patients will go on to develop epilepsy

  • Complex febrile seizures that appear well in the ED can still be discharged, but should be referred to neurology

Blunt Pediatric Trauma

  • Physical exam findings and risk of intra-abdominal injury requiring intervention

    • GCS <14 or seat belt - 5.4%

    • Abdominal tenderness - 1.4%

    • Chest wall trauma or vomiting - 0.7%

    • No symptoms - 0.1%

  • FAST Exam

    • Sensitivity 88% specificity 85% for hemoperitoneum requiring massive transfusion or exploratory laparotomy

  • LFTs and lipase

    • AST >200, ALT > 125

    • Lipase has the greatest specificity and positive predictive value

    • See Dr. Modi’s post here for more information on laboratory testing in pediatric trauma

  • Cervical spine injuries

    • PECARN risk factors for cervical spine injury

      • Altered mental status

      • Focal neurologic deficits

      • Neck pain

      • High risk motor vehicle collision

      • Diving injuries with an axillary load

    • Presence of one risk factor has a sensitivity of 98% and specificity of 26%

  • Blunt head trauma < 24 hours

    • Altered mental status or palpable skull fracture - 4.4% risk of serious TBI

    • Loss of consciousness, severe mechanism or injury, vomiting, severe headache, or abnormal behavior - 0.9% risk of serious TBI

    • No risk factors - < 0.5% risk of serious TBI