Grand Rounds Recap 1.2.19
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Great debate: Ketofol vs ketamine or propofol alone for procedural sedation WITH DR. settler and dr. calhoun
Ketofol
No standard definition; however, loosely is defined as a combination of Ketamine and Propofol administered for the purposes of procedural sedation either mixed together in a single syringe or administered separately.
Dosing is variable in the literature but one of the more common practices a ratio of one to one.
Theoretically these two medications can work with synergistic effect to counter the drawbacks of each individual medication. Propofol can help mitigate the sympathetic surge, recovery agitation, and nausea/vomiting associated with Ketamine. Ketamine can help to mitigate the hypotension, and lack of analgesia, associated with a pure Propofol sedation.
Literature has suggested that there is a trend towards a more “smooth sedation curve” with the use of Ketofol. This can lead to less need for additional doses of a sedative agent. Additionally, there has been a trend towards higher provider satisfaction scores with the use of Ketofol.
Ketamine or Propofol Alone
Most of the available literature focuses on comparisons between Ketofol and Propofol alone. There is limited literature comparing Ketofol to Ketamine alone.
Most of the available literature suggests that a combination of Ketamine and Propofol does not have decreased incidences of respiratory depression when compared to Propofol alone.
The available meta analyses that have been performed are of limited applicability to our ED population. There does not seem to be evidence to suggest combining Ketamine and Propofol to offer any significant clinical advantages over just using a single agent. Furthermore, adding in a second agent further raises the risk for medication administration error as you now must calculate, prepare, and administer two medications instead of just one.
Bottom Line
After review of the available literature Ketamine, Propofol, and Ketofol, all seem to be reasonably safe approaches to procedural sedation. It is important to use a patient centered approach and select the correct agent for the patient after weighing all the pros and cons. There is no clearly superior option for all patients.
discharge, transfer, or admit WITH DR. leenellett
Case 1
A female in her early 20’s presented to a community emergency department with a chief complaint of vaginal bleeding. She is G3P3 and gave birth vaginally to a healthy male child approximately four weeks ago. On that afternoon she had gone to the restroom when she felt a gush of fluid and looked in the toilet to see what was described as “a lot of blood”. Her husband immediately called 911 and she was transported to the emergency department.
On arrival was tachycardic to 115, with a low grade temperature of 99 and a blood pressure of 100/60. Her physical exam showed blood soaked through her clothing and onto the stretcher.
Lab work revealed a hemoglobin of 8 with normal platelets and normal coagulation studies.
This patient was transferred to a definitive care facility with access to OB/GYN surgical services via aeromedical transport.
Discussion: Post Partum Hemorrhage
Leading cause of morbidity and mortality worldwide.
Defined as one liter of blood loss rapidly or blood loss with signs/symptoms of hypovolemia within twenty four hours.
When evaluating these patients consider the 5 T’s in your differential diagnosis:
Tone: Uterine Atony accounts of 70-80%
Trauma: Lacerations, expanding hematoma, uterine rupture
Tissue: Retained placental tissue
Thrombin: Coagulation issues (DIC, vWF, etc)
Traction: Uterine inversion
Risk Factors: prior C section or uterine surgery, multiple gestations, >4 previous vaginal deliveries, history of prior post partum hemorrhage, large fibroids, placenta previa, history of clotting disorders.
Management:
Maneuvers: bimanual compression / uterine massage.
Pelvic packing
Medications: Oxytocin, Prostaglandins, Ergo Alkaloids, TXA
Definitive treatment may be dilation and curettage or hysterectomy so involvement of OB/GYN is essential.
Recognizing that these patients can decompensate quickly and will often re-bleed even after initial presumed hemostasis is key. Rapidly ensuring access to OB/GYN surgical service is paramount and therefore early engagement of transfer services is important.
Case 2
A female in her early 20s presented to a community emergency department with a chief complaint of a small amount of vaginal bleeding. She is G2P1 with a last menstrual period approximately four to six weeks ago. She took a home pregnancy test approximately one week ago that was positive. On the day of presentation she went to the bathroom and noted a pink tinge on the toilet paper. Concerned, she self presented to the ED.
On arrival her vital signs were all within normal limits. Her abdominal exam was benign and she complained of no abdominal pain. Her pelvic exam showed a small amount of pink tinged mucous in the vaginal vault; however, no active source of bleeding and the cervical external os was closed.
Lab work showed hemoglobin, platelets, and coagulation studies all within normal limits. Her urine pregnancy test was positive and a serum quantatative HCG resulted at 1800. A bedside ultrasound was performed that showed an empty gestational sac.
Discussion: Early Pregnancy of Undetermined Location
These patients can be challenging because it is often difficult to distinguish very early viable intrauterine pregnancy, early miscarriage, and early ectopic pregnancy.
There are different institutional practices regarding these patients so please refer to your departmental policies and combined approaches with OB/GYN when possible.
Many providers would agree that given the clinical uncertainty the patient needs a repeat HCG in 48 hours and close follow up with OB/GYN. This can be provided in many different ways including arranging follow up with an accepting OB/GYN or having the patient return to the ED. The discharge instructions are the key to success to ensure that the patient actually follows up appropriately.
Never forget to check the Rh status of the patient and given Rhogam when indicated to prevent downstream complications of hemolytic disease of the newborn in subsequent pregnancies.
R1 clinical diagnostics: massive transfusion protocols WITH DR. Laurence
Please refer to Dr. Laurence’s excellent TamingTheSRU post which goes into more detail about massive transfusion protocols. Below are some cases that were presented to highlight the learning points of that post.
Massive transfusion has different definitions in different clinical settings but most commonly is defined as meeting one of the following three conditions:
Receiving 10 units of packed red blood cells in a twenty four hour period
Replacement of the total blood volume in less than 24 hours
Replacement of 50% of the total blood volume in 3-4 hours
Case 1
A male in his mid twenties presented after sustaining a crush injury to the abdomen. He arrived by EMS, screaming with pain and complaining of back and abdominal pain. Initial vital signs per EMS were BP 135/85, HR 92, RR 18, SpO2 97% on room air. Repeat vitals in the SRU are BP 88/60, HR 125, RR 18, SpO2 95% on room air. Physical exam was notable for absent tracheal deviation, intact breath sounds bilaterally, diffuse abdominal tenderness with a stable pelvis. A FAST ultrasound exam was performed and was positive in the right upper quadrant.
Discussion
The ABC score (Assessment of Blood Consumption) score is a clinically validated assessment tool for determining the need for initiation of a massive transfusion.
There are four components (each worth one point):
Systolic blood pressure less than 90
Heart rate greater than 120
Positive FAST
Penetrating mechanism of trauma
Many providers will use a cut off of an ABC score greater than or equal to two for initiation of a massive transfusion based upon the available evidence.
In this patient his ABC score would be three (HR > 120, SBP <90, and a positive FAST). He would meet the indication for massive transfusion. There is some variability in the order that blood products are given; however, there is no disagreement that a balanced resuscitation is preferred ideally with a 1:1:1 ratio (packed red blood cells:plasma:platelets). The PROPPR trial showed decreased death from exsanguination with this strategy and the PROMMTT study showed that early administration of plasma and platelets was associated with decreased mortality in patients requiring at least three units of blood products in the first twenty four hours.
Case 2
A female in her thirties presented after being struck by a car on her right side while riding her bicycle approximately one hour prior to presentation. On arrival she was complaining of severe pelvic and right lower extremity pain. Her initial vitals signs per EMS were BP 124/72, HR 92, RR 18, SpO2 98% on room air. Repeat vital signs on arrival were BP 85/59, HR 117, RR 18, SpO2 98%. Physical exam was notable for equal breath sounds bilaterally, pallor with delayed capillary refill 3-4 seconds, abdominal tenderness to palpation diffusely, right hip pain with log roll, right femur deformity, and pelvic instability with lateral compression. A FAST was performed and was adequate and negative. There were no other signs of trauma.
Discussion
This patient highlights the limitations of the ABC score when applied very specifically without flexibility. Her ABC score would be calculated to be one (SBP < 90) which would not meet indications for massive transfusion; however, she is clearly very ill with likely significant source of bleeding given her continued decline. There are populations who are at risk for being missed when only using the ABC score. At risk populations include: young healthy patients with significant physiologic reserve, patients on medications that affect heart rate such as beta blockers. There are also logistical challenges that can impede the use of this clinical decision tool such as having an inexperienced ultrasonogropher perform your FAST exam or not performing repeat assessment of the patient’s vital signs.
Case 3
A male in his sixties presented to the emergency department after a tractor rollover accident. His initial vital signs were BP 88/60, HR 132, RR 18, SpO2 of 82% on room air. He had a diffusely tender right side of his chest wall and abdomen. His pelvis was unstable to lateral compression. He had diminished breath sounds on the right side and underwent needle decompression followed by tube thorocostomy with improvement his oxygen saturation to 95%. There was approximately 250 mL of bloody output from placement of the chest tube. A FAST was performed and was positive in the pelvis and he remained hypotensive and tachycardic despite the above interventions. Massive Transfusion protocol was activated for this patient.
Discussion
This patient clearly met indication for massive transfusion with an ABC score of 3 (HR >120, SBP <90, Positive FAST). In patients receiving massive transfusion you should also consider administration of calcium given the associated chlelating effects of the citrate found in the blood products. Failure to do can lead to hypocalcemia. Additionally, consideration of administration of TXA and placement of a pelvic binder can all help stem further blood loss.
Clinical pathologic case WITH DR. iparraguirre and dr. Lafollette
Case
Chief Complaint: Nausea, Vomiting, and Abdominal Pain
History of Present Illness: A male in his early forties presents to the emergency department with a chief complaint of nausea, vomiting, and abdominal discomfort. He has a past medical history of hypertension and GERD. He states these symptoms began approximately two weeks ago. The abdominal discomfort is described as an achy and burning sensation with associated bloating. The pain radiates to his throat and chest. It appears to be aggravated by food or when lying supine. He has had similar symptoms to this in the past which led him to have an endoscopy performed approximately one month ago where he was discovered to be positive for H. pylori and is currently being treated for this.
After taking the initial history he mentions that he is also concerned about left sided facial weakness that he has been having for approximately three weeks. It seems to be worse with chewing and at times is made worse with stress. His spouse who is also presents noted that she has noticed a change in his smile and dropping of left eyelid. He states that this all seems to have started during a recent trip back to visit family in western Africa around three weeks ago. He has no other neurologic complaints and the rest of his review of systems is negative.
Past Medical History: Hypertension, GERD (H. pylori positive currently being treated).
Past Surgical History: None
Allergies: None
Social History: Immigrated from western Africa and recently traveled back to visit family approximately 3-4 weeks ago. Denies tobacco, alcohol, or illicit substance use.
His vital signs were all within normal limits. His EKG showed T wave inversions in the lateral precordial leads and there were no EKGs available for comparison. His troponin assays were negative times two.
And then a test was ordered…
Diagnosis: Myasthenia Gravis
Test: Ice Pack Test
Discussion
Myasthenia Gravis is an autoimmune neuromuscular disease characterized by weakness and fatigability of skeletal muscles due to dysfunction of the neuromuscular junction.
In 80-90% of cases there are auto-antibodies against the acetylcholine receptor.
The incidence is low with only an estimated 7 to 23 new cases per million. There is a bimodal distribution with an early peak in the second and third decades of life in females and a late peak in the sixth to eighth decades of life in males.
The most common initial presentation is due to ocular symptoms of ptosis and/or diplopia. Half of those affected develop generalized disease within two years. Fifteen percent of patients present with bulbar symptoms including dysarthria, dysphagia, and fatigable chewing. Less than five percent present with limb weakness.
The Ice Pack Test has a reported sensitivity of 76% and specificity of 98%. The test is based on the physiologic principle that neuromuscular transmission improves at lower muscle temperatures. In patients with Myasthenia Gravis ptosis can be overcome by direct cooling of the eyelid muscles. The test is performed with direct application of an ice pack to the face of a patient affected with ptosis for approximately five minutes. Afterwards assessment for improvement determines a positive test. There are also serologic and electrophsiologic testing that can be performed but this is rarely, if ever, useful in the emergency department setting.
There are four therapies commonly used to treat Myasthenia Gravis:
Symptomatic treatments: Anticholinesterase agents
Chronic immunomodulating treatments: Steroids and other immunosuppressive agents
Rapid immunomodulating treatments: Plasmapheresis
Thymectomy
Take care to evaluate for the feared complication of Myasthenic Crisis. In this condition the patients respiratory status declines to the need for mechanical ventilation. You can help assess the need for elective intubation through serial respiratory function tests, blood gas assessments, breath counts, or assessing for signs of impending failure such as difficulty with secretions and worsening ability to speak.
R4 Case Followup: severe alcohol WITHDRAWAL WITH Dr. Colmer
Case
A female in her mid forties presented to the emergency department with a chief complaint of alcohol withdrawal. She had a significant past medical history of alcohol abuse disorder with multiple prior admission for both acute alcohol intoxication and alcohol withdrawal. She states that over the past year she had achieved sobriety following rehabilitation; however, approximately ten days ago she had a relapse and during that time has been consuming approximately one liter of vodka each day. She states her last drink was approximately eight hours prior to arrival.
On physical exam she appeared clinically intoxicated with alcohol. Her physical exam was otherwise normal and her vital signs were also normal. Her laboratory workup was negative except for a ethanol level of over 300 mg/dL. She was observed in the emergency department until she achieved clinical sobriety with no change in her vital signs or physical exam. She was seen by social work who provided her with resources to pursue alcohol detoxification in a safe setting and was ultimately discharged home in good condition.
Later that evening the patient returned to the emergency department with a chief complaint of fall. She was observed by a friend to have sustained a fall in which she struck her face on the ground and may have had some convulsive component to this. EMS was activated at that time but did not observe any seizure activity and she was brought to the emergency department.
On this visit she was found to be more tremulous than prior with a tachycardia of approximately 115. She was otherwise hemodynamically stable. Her point of care blood glucose was within normal limits. Lab work was again unremarkable other than at this time her ethanol level was undetectable. She was found to have a small laceration to the bridge of her nose and underwent both head and maxillofacial CT imaging all of which returned normal. She underwent repair of her small laceration. Given concern for alcohol withdrawal she was provided 10mg of oral Valium and ultimately admitted to the hospital for alcohol withdrawal.
As an inpatient she was placed on an Ativan based Clinical Institute Withdrawal Assessment protocol and was discharged approximately 48 hours later for planned placement in a rehabilitation center.
Discussion - Severe Alcohol Withdrawal
Alcohol dependency affects more than eight million people in the United States. Men are more affected than women. It is estimated that approximately fifty percent of individuals with alcohol use disorder with experience withdrawal symptoms with abrupt cessation and among those three to five percent will experience severe withdrawal symptoms.
The symptoms of alcohol withdrawal range from minor to severe.
Minor Withdrawal: Occurs 6 to 36 hours from the last drink. Symptoms include: tremor, mild anxiety, headache, GI disturbance, insomnia, palpitations.
Seizure: Occurs 2 to 48 hours from the last drink. Most often generalized tonic clonic seizures. These seizures are a distinct clinical entity from delerium tremens are are not accurate predictors of who will go on to develop more severe symptoms of withdrawal.
Hallucinations: Occurs 12 to 48 hours from the last drink. Usually visual; however, can be auditory or tactile. In the presence of an otherwise normal mental status these are distinct from delirium tremens.
Delerium Tremens (DTs): Occurs 48-96 hours from the last drink. Determined by the presence of disorientation, agitation, and autonomic instability including tachycardia, diaphoresis, hypertension, and/or being febrile. There is an associated increased mortality from the development of delerium tremens.
The rate of alcohol metabolism is difficulty to quantify and is affected by many different factors including age, gender, ethnicity, frequency of consumption of alcohol, recent meals, family history etc. A reasonable estimate for the average person is 20 mg/dL/hr but can be much higher in a patient who frequently abuses alcohol.
The development of withdrawal symptoms occur due to a decreased blood ethanol level below the level from which the patient typically habituates. It is important to remember that a positive ethanol level does not exclude the possibility of concomitant alcohol withdrawal. Distinguishing between acute alcohol intoxication and alcohol withdrawal can be challenging and requires a high index of suspicion.
Benzodiazepines are the most often cited first line therapy for alcohol withdrawal.
Selection of benzodiazepine is important. Comparing Valium to Ativan shows that Valium has a more rapid onset and longer half-life leading to more reliable assessment of efficacy (and need for additional administration) and less fluctuation in effect and for many providers is the preferred agent.
Valium should be avoided in patient’s with overt liver failure as indicated by known history of cirrhosis, scleral icterus, jaundice, caput medusa, distended abdomen with ascites etc; however, without overt evidence of such is generally considered a safe first line therapy.
Phenobarbital is making a resurgence in favor for the treatment of acute alcohol withdrawal.
Rosenson et al found in a prospective study of 102 patients that treatment with an upfront dose of phenobarbital (10 mg/kg) led to a decreased need for ICU admission.
Oks et al found in a ICU population that the use of phenobarbital instead of benzodiazepines did not lead an increased incidence of the need for intubation.
Many protocols, including ours on EmergencyKT, recommend the use of phenobarbital as a rescue adjunct following escalating doses of Valium. There are now proponents suggesting that phenobarbital may be a better first line agent than benzodiazepines but at this time this remains a clinical decision at the individual clinician level and is not yet considered standard of care.
R1 clinical knowledge: weapons of mass destruction WITH DR. urbanowicz
Weapons of Mass Destruction can be chemical, biologic, or radiologic that are sometimes combined with more conventional explosives.
Radiologic Weapons
Often thought of as nuclear bombs with massive explosion and subsequent devastation; however, these can be covert by exposing patients to a source of radiation. Symptom onset tends to be delayed and manifests over time.
The role of the ED in radiation exposure is for decontamination and minimizing morbidity and mortality through supportive care.
Biologic Weapons
The big six: plague, smallpox, tularemia, botulism, anthrax, viral hemorrhagic fevers
Smallpox:
Spread through aerosol.
Classic form of the disease has an approximate 30 percent mortality. Other more virulent forms approach 90 percent mortality.
Rash of smallpox tends to be more disseminated and confluent in the face and extremities in comparison to chickenpox.
Anthrax
Cutaneous infection: incubation period of one to five days followed by formation of a single papule when then forms a vesicle with regional lymphadenitis. The lesions rupture at approximately one week and then develop the classic black eschar.
Inhalation/Pulmonary Infection: Initially the patient experiences a non-specific viral illness. A latent period occurs next followed by acute deterioration over 24 to 48 hours with hemorrhagic mediastinitis with or without hemorrhagic meningitis.
The management consists of fluoroquinolones or tetracyclines. If there is evidence of systemic toxicity you include linezolid or clindamycin. If there is evidence of meningitis you include meropenem.
Plague
Initially asymptomatic during the first two to three days following inoculation. The first onset of symptoms are non-specific and flu-like. Over the next 24 hours a fulminant pneumonia-like illness occurs followed by sepsis, hemodynamic collapse, and usually death.
Chemical Weapons
Examples include nerve agents and vesicants. Causalities tend to manifest quickly and in large quantities if many are exposed. Water is considered the universal decontamination agent.
Clinical manifestations include flaccid paralysis, seizures, coma, and apnea.
Management is priority of airway control and medications including atropine, benzodiazepines, and pralidoxime (2-PAM).
R3 Small Groups: Neurologic Emergencies WITH DR. Klaszky, Dr. Murphy-Crews, and Dr. Gauger
National Institute of Health Stroke Scale
This exam is critical to accurate description of the severity of a stroke and is often used in medical decisions for inclusion/exclusion from a variety of modalities in the treatment of acute stroke.
It is recommended to perform a consistent neurological exam that you do in all of your assessments of stroke quickly to help make the determination for need for imaging/management and then go back with the assistance of a documenting tool to help rapidly calculate a formal score.
A recommended rapid neurological exam is:
Ask name, date, location
Provide two commands (“Stick out your tongue” “Show me two fingers”). A common mistake is to perform these in front of the patient as an example. The goal is to see if they integrate your verbal command and return a physical response.
Ask them to repeat a sentence you provide (“The sky is blue in Cincinnati”)
Have them smile and “puff” out their cheeks.
Evaluate their gaze evaluate for a blink response to threat
Evaluate strength and sensation in all extremities
Perform coordination testing (finger-nose-finger, and heel to shin)
Evaluating CT Angiography of the Head and Neck
Rapid identification of large vessel occlusions is imperative in the initial evaluation and management of stroke. Although most institutions will have access to a radiologist/stroke specialist to perform finalized formal reads of these images it is important for ED providers to become familiar with this as well.
As the primary physician evaluating the patient you have the advantage of having the patient in front of you. Allow your physical exam to help guide yourself to where you believe the lesion may be. Additionally, as emergency department physicians we are most concerned with large vessel occlusions that would be amenable to intervention leading to meaningful recovery.
A recommended approach to reading CT angiography of the head and neck imaging.
Have a system and practice it regularly each time you order these studies.
Be methodical in your approach.
Examine each pair of vessels starting at the arch of the aorta for symmetrical enhancement or abrupt cut-offs.
Start with axial images but use the coronals afterwards to focus on the posterior circulation specifically. There are vertebral/basilar occlusions that will be much easier to see on coronal imaging that would otherwise be missed if you only focus on the axial images.
Procedural Competency: Burr Hole
We specifically discuss this procedure in the context of CT confirmed acute epidural hematoma in the temporal region of a newly comatose patient.
The literature on the performance of this procedure in the ED setting is mainly limited to case studies/expert opinion.
Commonly accepted indications for performance of this procedure:
TEMPORAL epidural hematoma
Acute deterioration with a lucid interval. Deterioration is usually identified as development of obtundation, acute development of anisicoria.
Failure to respond meaningfully to more conservative measures (i.e. hypertonic saline, elevation of head bed, pain/sedation control, correction of underlying coagulopathy)
Inability to reach Neurosurgical definitive management in a “timely fashion”. Difficult to define what is considered timely; however, some advocate for 1-2 hours.
For those practicing in a tertiary referral center with ready access to Neurosurgical services this procedure would not be indicated. The same holds for the majority of cases where there is ready access to rapid transfer for Neurosurgical services. However, for those practicing in austere environments with limited resources this procedure could very well save the life of an otherwise healthy young person with an acute traumatic injury. As with all procedures that are rarely performed this requires a lot of mental exercise to ensure comfort with the indications, procedural steps, and materials required to successfully complete should the need arise.
