Grand Rounds Recap - 2/11/15

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Repeat 6 Hour Head CT in Mild TBI Patients with Dr. Kreitzer

By Rehman T, Ali R, Tawil I, Yonas H [CC BY 2.0 (http://creativecommons.org/licenses/by/2.0)], via Wikimedia Commons

By Rehman T, Ali R, Tawil I, Yonas H [CC BY 2.0 (http://creativecommons.org/licenses/by/2.0)], via Wikimedia Commons

Mild TBI = GCS > or = 13

  • Incidence of NSG intervention 0.9%
  • Mortality 0.1%

Why Consider a 6 hour CT scan?

  • Pros: quicker disposition, avoidance of unnecessary admission
  • Cons: extra radiation, does not address post concussive symptoms

ACEP policy: mild TBI patients with normal head CT and normal mental status can be discharged home

**See this article by Kreitzer, et al published in Academic Emergency Medicine for a review of the evidence behind the 6 hour CT scan

There are several prospective studies, mostly from trauma literature, that show that there are very few patients who require NSG intervention based on repeat head CT alone. Most patients who require interventions will have a deteriorating neurologic exam

  • Radiation risk: 1 in 8100 women who gets a head CT at age 40 will develop cancer from that scan
  • If there is lack of clinical and radiographic progression within 24 hours, the odds of a bad outcome are very low
  • It is likely unnecessary to do repeat imaging for those patients who have GCS 15 and no clinical deterioration
  • There is no evidence to suggest that a 6 hour head CT is necessary in patients with traumatic ICH

Alcohol Emergencies with Dr. Miller

**See this posts from Life in the Fast Lane and this nicely constructed table from Salim Rezaie of the Rebel EM Blog

Methanol: most toxic due to its metabolites

  • Can cause blindness in as little as 4 mL ingestions and death in as little as 10 mL
  • Optic neuritis with methanol ingestion: system onset 6-72 hours
    • Due to formic acid. 
    • Give folate to help metabolize
    • Patients complain of photophobia, blurry vision 
    • Hyperemic optic disk
    • Treatment with fomepizole

Alcoholic ketoacidosis: seen in chronic alcoholics with poor nutritional status and binge drinking

  • Abdominal pain, N, V
  • Normal mental status
  • Wide anion gap metabolic acidosis 
  • Low-normal glucose
  • Low Na, K, Mg and Phos
  • Treatment: thiamine, D5NS, replace their electrolytes
  • Usually will resolve in 8-12 hours so can be a CDU candidate

Isopropyl alcohol ingestion

  • Intoxication with high osmolal gap and no anion gap or acidosis
  • Metabolized to acetone, which will be excreted in urine
  • Twice as potent as ethanol
  • Symptoms: CNS depression, N, V, abdominal pain, ataxia
  • Can look like shock: hypothermia, hypoglycemia with renal/respiratory failure
  • Treatment: supportive
  • Can dialyze if isopropyl level > 400 orif pt has refractory hypotension or is in       a coma
  • Can dc home if asymptomatic 6-8 hours after ingestion

Ethylene glycol ingestion

  • Ca oxalate crystals in urine
  • Metabolic acidosis with anion gap and AKI
  • Glycolic acid is the toxic metabolite
  • Altered mental status
  • 3 phases: 
  1. CNS tox (0.5-12 h): nystagmus, hyporeflexia, seizures
  2. Cardiorespiratory (12-24): pulmonary edema, hypotension
  3. Renal (24-72): AKI, symptomatic hypocalcemia with long QT

Work up for suspected toxic alcohol ingestion:  osmolality, renal panel, UA, toxic alcohol screen

  • Indications for dialysis: renal failure, optic neuritis, persistent acidosis
  • Give these patients pyridoximine and thiamine to help metabolize the toxic alcohol
  • Have high level of suspicion for toxic alcohol ingestion because sometimes acidosis is delayed

Ethanol withdrawal: ethanol works by upregulating GABA receptors, so withdrawal can cause upregulation of excitatory neurotransmitters and lead to seizures

  • Give benzos
  • Withdrawal seizures occur 12-48 hours after last drink

DTs: tachycardia, hypertension, hallucinations, delirium

  • Give aggressive doses of benzos and give them frequently. 
  • Literature favors diazepam
  • These pts do not need antiepileptics except for benzos

R4 Simulation with Drs. Ford, Cousar and Bohanske

Anaphylaxis

** See this post from EMBasic for more information about the diagnosis and treatment of anaphylaxis

  • Definition: involvement of 2 or more organ systems or 1 organ system with hypotension
  • Be aggressive in giving epinephrine.
  • There are a lot of deaths attributed to anaphylaxis that could have been prevented because providers are hesitant to give Epi

Biphasic reaction: recurrence of anaphylaxis within 72 hours of first reaction

  • This can occur at any time between hour 1 and 72, so there is no need to admit patients if they are asymptomatic. 
  • It is reasonable to observe for 4-6 hours
  • Seen in 2-20% of patients with anaphylaxis
  • See this article from Annals of Emergency Medicine by Grunau, et al for more information about biphasic reactions

When discharging these patients, make sure they go home with an Epi pen and a prescription for an Epi pen with refills

Treatment of Anaphylaxis

  • If the patient is wheezing, it is reasonable to give albuterol
  • Other therapies: steroids, H1 and H2 blockers
  • It is ok to give multiple doses of IM Epi Q2-5 minutes up to 2-3 times
  • If the pt is in refractory anaphylactic shock, can advance to push dose or vasopressor drip
  • Patients who take beta blockers are more likely to have refractory anaphylaxis
    • Respond well to glucagon

Oral Boards with Dr. Conine

Case 1: Epiglottitis

Case 2: Retropharyngeal abscess

  • Patients present with trismus, sore throat, fever and posterior pharyngeal erythema without masses or asymmetry
  • Treatment: steroids, broad spectrum abtibiotics
  • CT to evaluate whether this is cellulitis or abscess
  • If abscess, will need to go to OR

Procedure Station: NP scope

  • Indications: swelling, burns, dysphagia, mass, hoarseness, stridor
  • Contraindications: none
    • Be careful in patients with facial fractures and in patients with epiglottitis
  • Place patient in sniffing position and sitting upright
  • Anesthesia: nebulized and/or automized lidocaine
  • Explain the procedure to your patient to get buy in and full cooperation

Combined PEM/EM Lectures

Updates on Bronchiolitis in healthy infants 1-23 mo 

**For some more in-depth discussion on bronchiolitis see this great series of posts from PEMBlog and this recent EMCases

Bronchiolitis is a viral lower respiratory infection with inflammation and edema of small airways and excessive mucus production

  • RSV is the most common cause
  • 95% of kids will get RSV within first 2 years of life
  • Diagnosis should be based on H+P alone

Red flags: prematurity, cardiac disease, pulm disease, immunodeficiency, apnea, tachypnea (RR>60)

Recommendations for Diagnosis and Treatment

  • No need for labs/imaging in kids without red flags
  • Do not do viral PCRs unless the kid is admitted to ICU
  • Kids who get CXR are more likely to be put on antibiotics unnecessarily
  • Albuterol is not recommended: may see transient response but no difference in outcomes or disease resolution
  • Racemic epi is not recommended
  • Nebulized hypertonic saline: not recommended in ED, may be helpful in pts requiring prolonged inpatient stay
  • No role for systemic steroids
  • No need for supplemental O2 if O2 sat > 90%
  • If spot check is > 90, no need for continuous pulse ox
  • No role for antibiotics
  • BBG suction is your first line therapy
  • High flow nasal cannula decreases need for intubation

Tips and Tricks to Pediatric Physical Exam

  • Sit down, make it a game, save the worst for last 
  • Don't ask permission and don't lie
  • Engage the parents
  • Gait assessment: ask them to walk to parent or walk with the parent
  • Assess fontanelles when the kid is sitting up and calm
  • Femoral pulses: do not push hard, straighten legs
  • Liver edge: neonate 3.5 cm below costal margin
  • Mottling on extremities alone can be normal. full body mottling is concerning. 
  • C spine: palpate first and if no swelling or step offs, can assess mobility. if can move neck without difficulty, can clear clinically

CPC with Drs. Roche and Thomas

23 yo F who is 3 weeks postpartum presents from jail with new onset of altered mental status and seizures. She is agitated and tachycardic. Not oriented but alert. Labs unremarkable. CT head with diffuse small areas of subarachnoid hemorrhage and small ICH.

  • Altered mental status + HA + Sz: meningitis, encephalitis, mass, ICH, vasculitis, EtOH withdrawal
  • Sz + recent incarceration: hypoglycemia, EtOH withdrawal, trauma, tox
  • Sz + postpartum: eclampsia, cerebral venous sinus thrombosis, postpartum vasculopathy

Diagnosis: venous sinus thrombosis

  • This is a commonly missed diagnosis and patients usually see multiple providers prior to diagnosis
  • Symptoms: HA is the first and most common symptom
    • 50% will have increased ICP: seizures, focal neuro deficits, papilledema
  • Clues on CT head: edema and multiple areas of small hemorrhage
    • Cord sign or dense triangle sign: hyperattenuation of thrombus in the sinus
  • CTV vs MRV: MRV is probably better, but CTV is sufficient and more readily available
  • MRV is the test of choice if you can get it
    • Useful for dating the clot and looking for sequelae of the clot
  • Treatment:
  • Supportive therapy: ABCs
  • Treat the clot: heparin drip, though this is controversial due to high risk of hemorrhage. Low dose and no bolus. Repeat head CT when therapeutic
  • Can also do direct catheter thrombolytics, but that is last ditch effort and not        recommended due to even higher risk of bleeding
  • Seizures: if you seize once, you are likely to seize again, so you need anti epileptics. if the pt did not have a seizure, you do not need to start any anti-epileptics
  • Increased ICP: can do large volume LP, acetazolamide
  • Prognosis is pretty favorable

EBM Quick Hit with Dr. Selvam

Confounding: distortion of the association between exposure and outcome that occurs when studies differ with respect to some factor that influences the outcome

Confounders affect both the risk factor of interest and the outcome

How to control for confounding?

  • Restriction: limit your demographic groups
  • Matching of your subjects with similar controls
  • Randomization

Interaction aka effect modification: magnitude of the effect of primary exposure on an outcome differs depending on a third variable

  • Exposure has different impact in different circumstances

Important to know this in order to delineate high risk group