Grand Rounds Recap - 1/14/15

Oral Boards with Dr. Roche

Case 1 - 37 yo F, G3P2, no prenatal care, somewhere around 3rd trimester, presents with vaginal bleeding. She endorses feeling weak and dizzy and had 1 syncopal episode at home. On arrival, she is tachycardic and hypotensive (80s/60s), has cool extremities with weak peripheral pulse. Fundus is a few cm below xyphoid process. On a sterile speculum exam she has a large amount of bleeding and cervix is dilated to 3 cm. US shows IUP with good cardiac activity. She requires blood rescuscitation and admission to OB for delivery due to placenta previa.

• If you are concerned about placenta previa, oral boards wants you to confirm placenta position first (get ultrasound) prior to doing a pelvic exam. In reality, it may be ok to carefully do a sterile speculum exam, but do not perform a digital exam. 
• Also, oral boards wants you to begin fluid rescuscitation as soon as you see low BP, so it is ok to start IV fluids and then switch to blood once it becomes clear that this is hemorrhagic shock. 

By James Heilman, MD (Own work) [CC BY-SA 3.0 (http://creativecommons.org/licenses/by-sa/3.0) or GFDL (http://www.gnu.org/copyleft/fdl.html)], via Wikimedia Commons

Case 2 - 37 yo M presents with palpitations and dizziness. HR is in 180s with normal BP. He is in wide complex, regular tachycardia on EKG. Exam is unremarkable. He received procainamide and BP decreased to 90s systolic. He also had worsening dizziness, so he got sync cardioverted into NSR with short PR interval concerning for WPW. Admitted for observation and cardiology eval as this was not his first episode.

• WPW tachycardia is due to accessory pathway conduction
• If a patient presents with wide complex regular tachycardia, it is ok to try adenosine first if they are stable (though don't rely on the response to adenosine to determine whether or not the rhythm was SVT)
• It is never wrong to go straight to cardioversion

Oral Boards with Dr. Blomkalns

Case 1 - 57 yo F, pedestrian struck. Complains of RLE pain. No LOC. On exam, she has HR 120, BP 100/60. Primary survey is intact. On secondary survey, she has an abrasion on her forehead, mild diffuse abd ttp, unstable pelvis and open R ankle fracture with intact pulses. She receives 1 L crystalloid and 1 u pRBCs, BP decreases to 80s/60s. T-pod is placed, massive transfusion is initiated. FAST is positive. Trauma is paged but are busy with GSW in the OR. CXR is negative. Pelvis x-ray shows an open pelvis. Trauma is unavailable, so your other option for unstable bleeding pelvis is IR embolization.

• Always check tetanus status in trauma
• If this patient needs central access, go above femorals as she is bleeding into her pelvis. 
• If a consultant is not being helpful, think of what other options are available (IR, ortho, ?transfer)

Case 2 - middle aged M with perianal abscess, hemodynamically stable with no systemic signs of infection

• It is ok to drain these on your own, as long as there is no perirectal involvement
• Check out these great podcasts by Rob Orman on perirectal and perianal abscess management: (A Primer on Butt Pus) (Perianal Abscess)

Oral Boards with Dr. Hinckley

Case 1 - 36 yo M presents with CC rash. He was seen in ED 5 days prior for abscess, had I&D and started on antibiotics. 1 day later he developed rash and now has flu-like symptoms as well as sore throat, fatigue, fever. On exam, HR 112, BP 96/58, T 100.6. He has a bullous rash on his entire trunk with positive Nikolsky sign (skin sloughing with gentle traction). In addition, he has bullae and edema of his posterior oropharynx and uvula. Diagnosis: TEN (toxic epidermal necrolysis)

• TEN = rash > 30% of TBSA
• Steven Johnson's = rash < 30% TBSA
• Treatment: aggressve fluid rescuscitation, pressors as needed. Broad spectrum antibiotics. Airway management (this patient got an awake look intubation). Cover wounds. 
• Admit to burn ICU
• General tip: always do an entire head to toe exam, even if that is not something we may do in real life

Case 2 -  56 yo F presents with sudden, acute burning LLE pain and tingling

• P 140 and irregular. A.fib with RVR on EKG
• LLE is pale and cool, no palpable pulses. Very weak dopplerable PT. 
• Diagnosis: arterial embolus to LLE due to a.fib
• Management: heparin drip and vascular surgery consult

Simulation with Dr. Hill

Case 1 - middle aged M with ESRD on HD presents with "abnormal labs" and dyspnea. He has not had dialysis in 5 days. K at PCP office was elevated. Pt waited until 1 AM to present to ED. Labs, EKG ordered and physician gets busy in SRU with sick patient. After the doc comes back, the pt is angry that they have not been able to get blood despite multiple sticks and wants to leave

• Can sign out AMA if pt has capacity and is able to understand risks and benefits. 
• Try defusing the situation by letting the patient vent and sitting down
• Try offering other solutions 
• Always make it clear that the pt can come back at any time if they change their mind
• Always give discharge instructions/prescriptions and return precautions
• Check out the most recent post on TamingtheSRU for more information about AMA discharges

Case 2 - young male with hx of alcoholism and varices presents with hematemesis. On arrival, not mentating well. Tachycardic and hypotensive.

• Management of variceal bleed: Airway protection. Aggressive blood product rescuscitation. Keep in mind that these patients are coagulopathic and thrombocytopenic, so give FFP and platelets. PPI/Octreotide drips. Rocephin for SBP prophylaxis.
• When your consultant does not want to do a certain intervention, try asking them coming to bedside to evaluate the pt
• It is easy to get angry with unhelpful consultant, however that is counterproductive and won't get you anywhere
• Can always bump it up the chain and ask to speak to attending

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Peds Oral Boards with Dr. Cyriac

Case - 3 mo old M former full termer with nausea, vomiting and lethargy with tachycardia on exam and looks dry but no other exam findings 

• DDx for the vomiting infant include: Pyloric Stenosis, Malrotation, Intussussception, NEC (though really only in the neonatal period), Milk Allergy, Metabolic Derangement (the most common is CAH), ICH/NAT, and sepsis
• Pyloric stenosis classically presents at 3-12 weeks of life and is typically nonbilious emesis
  • Less patients with pyloric stenosis are presenting with the classic "olive-shaped mass" in the epigastrium because the availability of ultrasound
• Malrotation typically presents with bilious emesis and is typically in younger infants, under 2 months but can present anytime in the first year of life
• Congenital Adrenal Hyperplasia classically presents from 2-5 weeks of life and has the classic findings of adrenal insufficiency on metabolic panel (hyponatremia, hyperkalemia, and hypoglycemia)
• Patients with CAH often tolerate hyperkalemia better than adults because of chronicity of the rise in potassium
• Try to draw metabolic labs before treating the metabolic abnormalities (i.e. glucose and steroids) in CAH

Peds Oral Boards with Dr. Sterrett

Case - A 1 week old male former full termer with home birth presents to the ED with vomiting with brown material in emesis and bruising on skin exam

• Coagulopathy in a neonate DDx: DIC due to sepsis, disseminated HSV infection, Vitamin K Deficiency (likely due to lack of administration at birth)
• Hemoglobin reaches its physiologic nadir at 4 weeks
• Treat disseminated coagulopathy with FFP (10 cc/kg)
• Formula fed neonates often will receive adequate Vitamin K as formula is fortified with it

Peds Oral Boards with Dr. Gong

Case 1 - 6 mo old M presents with left lower extremity swelling and obvious step-off on exam found to have a femur fracture on x-ray

• NAT always has to be a serious consideration for any child with bruising and injuries when they are too young to cruise
• Skeletal survey is necessary in any infant with concern for NAT
• Wormian Bones - skull bones that appear like puzzle pieces, are suggestive of difficulty with ossification, such as osteogenesis inperfecta
• OI is fairly rare and can certainly be mistaken for NAT, but NAT must be ruled out while the work-up for OI is on-going
• Children with NAT who have AST/ALT of greater than 80 should prompt a CT Abdomen/Pelvis as this is suggestive of intra-abdominal trauma

Case 2 - 2 yo F presenting with 3 days of fever, macular xanthem, swollen, cracked lips, and extremity swelling

• Kawasaki's Disease requires 5 days of fever, and 4/5 symptoms of conjunctivitis, mucositis, lymphadenopathy, trunkal rash, and swelling of the extremities
• Incomplete KD must include some element of fever and symptomatology but can be further evaluated with lab criteria
• KD is associated with cardiac lesions, especially cardiac artery aneurysms, which often present within 10 days of symptom onset
• IVIG is the treatment of choice and while high-dose aspirin is still classically given the evidence on this is equivocal
• Other considerations on the differential for KD include Staph Scalded Skin/TEN/SJS, and Scarlet Fever

Kawasaki Disease. By Dong Soo Kim (Kawasaki disease.) [CC BY 2.0 (http://creativecommons.org/licenses/by/2.0)], via Wikimedia Commons

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Neuromuscular Emergencies with Dr. Renne

Gullian-Barre Syndrome is classically a vertical paralysis, associated with hyporeflexia triggered by infection

• While GBS is rare these patients can develop significant mortality and morbidity downstream as many as 1/3 require intubation
• GBS patients classically presents with absent reflexes, normal pupils, and symptoms are not fatiguable
• LP results can include a mild leukocytosis but have elevated protein, but is not highly sensitive
• Treatment for GBS includes plasma exchange and IVIG, but avoid steroids
• Be sure to do a thorough skin exam for any signs of ticks as tick paralysis can mirror GBS

Myasthenia Gravis presents with fatiguable weakness, especially diplopia and ptosis and is often related to cancer diagnosis

• There is a higher prevelance of MG in part due to the slow progression of disease as antibodies attack the neuromuscular junction
• Patients present with normal reflexes and pupils but their symptoms are often associated with fatiguability
• Diagnosis is through Anti-ACH antibodies, but clinically you can attempt a Tensilon test (keep in mind that tensilon will worsen an anticholinergic crisis)
• Treat with anticholinergics, plasma exchange, and IVIG

Botulism is classically descending weakness with associated GI symptoms and anticholinergic symptoms

• Botulism is rare and should always be on the DDx for dysphagia
• Classically botulism is associated with dilated pupils (due to the Anti-cholinergic symptoms)
• Treatment is via the anti-toxin which has to be ordered through the CDC

Providers must vigilantly assess the airway in patients with neuromuscular emergencies as they can often develop occult ventilatory failure as a result of their illness

• An effective bedside test to assess patients airway with neuromuscular emergencies is the exhaled digit span (the patient in a single expiration counts as high as they can
• FVC and NIF are both tests to use to assess when a patient may need to be intubated.  FVC of less than 15cc/kg and NIF of less than -15 should indicate a need to intubate
• Consider rocuronium as a paralytic in patients with neuromuscular emergencies as succinylcholine has been associated with hyperkalemia in GBS and botulism and decreased function in myasthenia

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Case Follow-Up with Dr. LaFollette

Calcium channel blocker overdoses can cause significant hemodynamic instability but is often associated with preserved mental status

Treatment for CCB overdose can include decontamination (if they present within the first hour of ingestion), fluid resuscitation, calcium, and high dose insulin (1 unit/kg bolus and then a drip at 1 unit/kg/hr), and then vasopressors as needed

In patients that take a reported CCB overdose who arrive asymptomatic, observation for 8 hours should be adequate, unless the ingestion was of extended release formulation, then observation periods should be for greater than 24 hours

Intralipid for CCB is a consideration, but anecdotally it seems to work better for verapamil than amlodipine

Methylene blue is a consideration for patients with persistent hypotension based on several case reports in part due to its ability to scavenge nitric oxide

For more information on calcium channel blocker overdose, check out this podcast by Scott Weingart and Leon Gussow