Grand Rounds Recap - 10/22/14

M&M Learning Points with Dr. Mike Bohanske

Acetaminophen can be one of the most dangerous drugs in overdose, as the toxic dose of acetaminophen is 250 mg/kg

There are 4 stages of acetaminophen overdose:

Proper way to check for fluorescence is to pour the urine out of a cup and check with a Woods Lamp

• Stage 1 from 0-24 hours when labs may be normal but the patient has nonspecific symptoms such as nausea, vomiting, and fatigue
• Stage 2 from 24-72 hours when labs may be normal or be trending upward but the patient is asymptomatic
• Stage 3 from 72-96 hours when significant metabolic derangement can occur such as profound metabolic acidosis, florid liver failure, and AKI.
• Stage 4 takes place only if you are able to get them through the acute illness precipitated in Stage 3 when hopefully recovery takes place, though there is no guarantee of liver recovery
• Use the Rumack-Matthew nomogram to determine the need to treat, the downside is you need to know the time of ingestion and this needs to be a single acute ingestion to apply it
• Treatment is with N-acetylcysteine (NAC) based on a 4-hour APAP level and should be initiated as soon as the 4-hour level returns
• If the time of ingestion is unknown and any signs of liver injury it is still work starting NAC
• NAC has a high co-incidence of anaphylactic-like reaction (10-20%) and there is correlation with how quickly it is given

Not all urine that fluoresces is ethylene glycol, in fact urine high in bilirubin can even cause it to fluoresce

Sepsis is a dynamic illness that requires vigilance to both identify and treat effectively

• Source control and time to antibiotics is essential, mortality has been demonstrated to be directly correlated to time to antibiotics
• Ertapenem is a carbapenem which can be useful for some intra-abominal infections but does NOT cover MRSA, Pseudomonas, or Enterococcus, thus limiting its use as a broad spectrum antibiotic
• While new studies such as ProCESS and ARISE continue to shine light on the way we resuscitate septic shock, neither proved that EGDT is unnecessary.  Instead, they likely both highlighted just how far "usual care" has come in terms of aggressively identifying and treating septic shock.
• ARISE and ProCESS have shown that all aspects of the intensive "Rivers Protocol" approach to sepsis may not be necessary (i.e. invasive access and ScVO2 monitoring), but we should still aim for an early goal directed therapy of septic shock.

Spinal epidural abscess (SEA) may be increasing in incidence with increasing heroin use

• Remember that IVDU is by no means the only risk factor, recent instrumentation, DM, and ESRD all increase your risk significant for spinal epidural abscess
• The classic triad of back pain, fever, and neurological deficits do not all have to be present, have a high suspicion in anyone with the right constellation of risk factors with back pain
• SEA are notorious hard to diagnosis and on average patients required at least 2 ED visits before diagnosis, but sometimes as many as 8 visits!
• On average a SEA spans ~4 spinal levels but can be occult and so be sure to expand the search to include all appropriate spinal levels with imaging
• Thoracic spinal cord disease can be notoriously hard to localize so be sure to do an appropriate neurological exam if ordering imaging

Other Learning Points

• Do not forget about the importance of informing patients of incidental findings during their ED work-up verbally and in writing
• Trauma usually has a cause - if someone does not know why they were in a single-vehicle car accident, start searching for something more insidious than just traumatic injuries, cardiac incidents often precipitate trauma

---

Update on Therapeutic Hypothermia with Dr. Bill Knight

Until recently the classic teaching was that the Number Needed to Treat for Therapeutic Hypothermia (TH) in post-cardiac arrest patients was 6.  However, the Targeted Temperature Management (TTM) study has raised some questions on the utility of 33C TH vs. maintaining euthermia at 36C post-arrest, but certainly this highlighted that 36C seems non-inferior to 33C.  It can be difficulty to compare studies in a field as dynamic as cardiac arrest research as resuscitation science has come a very long way quickly.

We still have no way of prognosticating who will do well after cardiac arrest and who will not.  Typically this determination cannot be made until 72+ hours without any extenuating circumstances (i.e. early signs of anoxic injury on CT)

Consider discussing early cardiac catheterization for post-arrest patients as there is data to indicate this may have mortality benefit, but this should not delay cooling

---

Adrenal Disease with Dr. Ludmer

Adrenal Insufficiency (AI) is difficult to diagnose due to the nonspecific symptoms and often can take years to diagnose with multiple incorrect diagnoses initially

• Symptoms can range dramatically but almost always include anorexia and generalized weakness/fatigue.  You should consider it as one of the "next great imitators" (along with Lupus, HIV, and Syphilis)
• The metabolic panel can be very telling and AI should be seriously considered in anyone with hyponatremia, hyperkalemia, and hypoglycemia
• Hyperpigmentation is the classic physical exam finding in primary adrenal insufficiency
• AI can be worked-up in the outpatient setting and does not necessarily need admission unless the patient has hypotension, significant electrolyte abnormalities, or has no access to follow-up

Adrenal crisis occurs when the symptoms of AI progress to cause refractory shock state

• If you're considering adrenal crisis a random cortisol of <15 mcg/dL significantly increases your post-test probability of disease, while a random level of >34 mcg/dL makes it fairly unlikely.  Consider a cosyntropin stim test if the patient has a level between 15 and 34.
• There is conflicting data on the utility of corticosteroids in septic shock based on results from the Annane and CORTICUS trials.
• Annane was based in a much more acute phase of septic shock and seems to have some more applicability to the ED population and thus its results, which do show a mortality benefit for steroid use might be more appropriate to generalize to ED patients

---

Case Follow-Up with Dr. Denney

27yoM w/stable wide complex tachycardia requiring multiple anti-arrhythmics and cardioversions

By Glenlarson (Own work) [Public domain], via Wikimedia Commons

The differential diagnosis for wide complex tachycardia in the ED is either ventricular tachycardia versus SVT with aberrancy.  Unless you are sure that a wide complex tachycardia is sinus tach with aberrancy than assume that it is ventricular tachycardia

• Stable ventricular tachycardia can be treated with procainamide, amiodarone, or synchronized cardioversion (both procainamide and amio can precipitate hypotension forcing a cardioversion)
• Patients with episodes of stable VT require admission to determine a cause and for assessment of implanted automatic cardioverter-defibrillator