Grand Rounds Recap 1.10.18

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"EMERGENCY MEDICAL TREATMENT AND LABOR ACT" (EMTALA) REVIEW WITH DR. HINCKLEY

Background:

  • EMTALA is a law that was written in 1985, enacted in 1986
  • Law was made in reaction to increase in hospitals refusing to see / accept patients who were unable to pay their bill, as well as transferring inpatients to other hospitals once they were no longer able to pay their bill.  
  • Essentially, the law is aimed to ensure adequate assessment and safe care/transfer of patients regardless of their income.
  • Applies to all Medicare-participating hospitals
  • Execution and regulation is performed by Center for Medicare/Medicaid Services (CMS)
  • Remains an unfunded mandate, though violations can result fines as well as the hospital no longer receiving reimbursement from CMS

Main Components:  Screen, Stabilize, and Transfer

  • Screening:  Medical Screening Exam (MSE)
    • Definition initially nebulous, and remains vague despite attempts at more formalized wording
      • CMS definition:  "An exam that is reasonably calculated to detect an emergency medical condition"
        • Emergency Medical Condition (EMC) further defined: "Acute symptoms, which may include severe pain, of sufficient severity to suggest that the patient's health may be jeopardized"
        • Includes active labor in an otherwise healthy woman
    • Important points
      • Must be performed by an accredited provider
        • Usually a physician
        • APPs can be accredited to perform the MSE
      • MSE should not be delayed to ask about finances
      • MSE should not be delayed while waiting for HMO approval
      • All hospitals, regardless of whether they have an ED or urgent care center, are required to provide a MSE prior to transfer
  • Stabilization
    • "Stable" is defined as reasonably likely that the patient will not deteriorate / decompensate during transfer 
    • If an EMC is identified, hospital is responsible for stabilizing patient prior to transfer
    • If no EMC is identified, no need for stabilization
  • Transfer
    • Circumstances under which a patient may be tranferred
      • Patient is stable
      • Patient or legal representative requests the transfer, and accepts the documented risks (In writing).  
      • Patient is unstable, and the current hospital lacks the capability to adequately stabilize/treat the patient
    • Requirements of transferring hospital
      • Select appropriate means of trasnport (i.e. ALS, BLS, HEMS, etc)
      • Sending facility/MD is responsible for what goes on during transport
      • When transferring an unstable patient, you essentially sign an "oath" that the benefits of transfer truly outweigh risks
    • Requirements of a referral center / Tertiary care center
      • If the referral center has the capacity and capability to care for the requested transfer, they must do so.
      • Cannot make acceptance contingent on use of any particular transport program (Ex. "We'll only take the transfer if you use our "X" for transfer)
      • Must report any EMTALA violations within 72 hours.  

Enforcement:

  • Frequency
    • Increased in the 1990-2000s
    • General downtrend since 2002
  • Repercussions
    • Mostly results in fines
      • Average fines recently increased due to inflation adjustments
      • Most suits are filed against hospitals as a whole
      • Individual physicians can be held accountable/fined.  
    • May result in Medicare/Medicaid (CMS) Pulling reimbursement from the hospital, which can be devastating.
  • Unlike malpractice, patient outcomes do not factor in to whether or not a violation is fined/reported.  Any violation can be reported, regardless of whether or not the patients outcome was affected.

Case Examples:

Case 1: 

  • Case:  A patient presents to a community hospital's ED with abdominal pain.  He has a known history of PUD, and is found to have free air on acute abdominal series.  The outside hospital has surgeons on call under normal circumstances.  However, recently the surgery group at the outside hospital decided not to take call until they can negotiate a better contract, and no surgeon will come in to take care of the patient.  The ED physician then requests transfer to the regional referral center to further care for/stabilize this patient.  Is this an EMTALA violation?
  • Discussion:  Yes.  The hospital technically has the capacity to stabilize this patient under normal circumstances, and transferring the patient prior to stabilization would be an EMTALA violation.  However, ultimately the patient should not suffer as a result.  Consensus was that the accepting referral hospital should still accept the patient, but then report the event as an EMTALA violation.

Case 2:

  • Case:  Patient was admitted to a rural hospital for pneumonia.  During his stay, he develops hemoptysis, hypoxia, and hypotension.  He is diagnosed with a PE, and requires ICU level of care which the rural hospital does not have.  Decision was made to transfer the patient to the referral center's ED.  Is this an EMTALA violation, or should the patient be admitted directly to the ICU.
  • Discussion:  Patients should not be transferred to a lower acuity area.  However, the ED is able to care for the critically ill.  Consensus was that this was not an EMTALA violation, but in order to improve patient's throughput the accepting physician might help facilitate getting the patient either directly admitted to the ICU or to definitive care (i.e. cath lab for EKOS)

Case 3:

  • Case:  Patient presents to an outside hospital.  He has a history of esophageal varices, has had large amounts of hematemesis, and is found to be hypotensive.  ICU level care is unavailable at the OSH, and decision is made to transfer the patient to the large referral center.  Large referral center states that they will accept the transfer to their MICU, however, with the caveat that they use their own critical care transport team as they carry blood products.  Is this an EMTALA violation
  • Discussion:  EMTALA laws state that is the responsibility of the sending physician to determine the means of transport and level of care necessary.  Accepting hospitals are unable to make the acceptance of a transfer contingent on the use of a particular transport service.  So in this case, consensus was that this is indeed an EMTALA violation.  However, it is reasonable for the accepting hospital to suggest certain methods of transport that may be more appropriate in terms of patient stabilization, but the acceptance cannot be contingent on such suggestions.  

Case 4:  

  • Case:  A patient from a nursing home is seen in the emergency department for cellulitis.  He is bed bound at baseline, and requires transportation to get to the ED.  His vitals show a borderline blood pressure, however, the provider determines that the patient is likely safe for discharge back to his nursing facility with oral antibiotics.  The patient is discharged, however, he remains in the ED to await for transfer out as he is bed bound.  During transport, the patient decompensates and becomes hypotensive.  Is this an EMTALA violation:
  • Discussion:   Consensus within the group was that this technically is not an EMTALA violation, as the patient had been deemed stable by the ED provider.  He was also not being transferred to another facility for additional stabilization, and was simply being transported due to lack of mobility.  It is an unfortunate outcome, but not necessarily an EMTALA violation.

Summary/Take Home Points

  • Medical screening exams for all
  • Do not delay MSE to ask about insurance or finances
  • There are 3 circumstances in which a patient can be transferred:  Stable patient, patient requests transfer, or patient is unstable and requires outside resources
  • Regional referral centers must accept transfers if capable

PHARMACY UPDATES: Anti-Epileptic Medications (AEDs) WITH NICOLE HARGER AND MADELINE STEPHENS, pharm-D's.

Objectives:

  • Review American Epilepsy Society Guidelines
  • Review medications for status epilepticus

Background

  • Epidemiology of seizures / status epilepticus
    • 200,000 new seizure cases annually
    • Most occur between <2 and >65 years old
    • Account for 1-2% of ED visits
    • Status epilepticus
      • 50,000 - 150-000 cases annually
      • Mortality is higher in adults
        • Peds < 3%
        • Adults > 30%

Classifications of seizure per American Epilepsy Society Guidelines

  • Types of seizure
    • Generalized:  Abnormal firing in both hemispheres
      • Primary:  Begins diffuseley
      • Secondary:  Begins with focal seizure that evolves/spreads to become generalized
    • Partial:  Abnormal firing limited to one hemisphere
      • Simple:  No AMS or LOC
      • Complex:  Confusion, AMS, or LOC associated with seizure
  • Duration of seizure
    • Brief seizure:  <5 Minutes
    • Prolonged seizure:  5-30 Minutes
    • Status
      • Seizure > 30 minutes
      • 2 Sequential seizures without return to baseline
      • May be convulsive or non-convulsive

Management of status epilepticus

  • 1-5 Minutes:  Seizure "First Aid"
    • Supportive care
    • EKG
    • Glucose
  • 5-20 Minutes:
    •  Benzodiazepines
      1. Proven to be safe (Trials comparing benzos and placebo:  placebo had more complications)
      2. Benzodiazepines proven more effective as initial therapy
      3. Trials comparing Lorazepm (Benzo) to Phenytoin for 1st line therapy
  • 20-40 Minutes:
    • 2nd Line therapy
      • Currently, all options thought to be equally efficacious
      • Options
        • Fosphenytoin 20mg/Kg
          • Tolerated in large doses better than phenytoin
        • Valproic Acid 40mg/Kg
        • Levetiracetam 60mg/Kg
          • Often underdosed
          • Thought to have a lower side effect profile/less toxicity
          • However, there appear to be reports of increasing numbers of psychiatric complications with high dose Keppra
  • 40-60 Minutes:
    • Will likely need to control airway
    • Repeat second line therapy OR Begin Anesthetic
      • Propofol
      • Midazolam drip
      • Pentobarbitol
      • Thiopentol 

AED Use for Seizure Prophylaxis in Trauma

  • Indications for seizure prophylaxis in trauma
    • Within the first 7 days
    • Initial GCS <10
    • Cortical contusion
    • Depressed skull fracture
    • EDH, SDH
    • Penetrating traumatic brain injury
    • Seizure within first 24 hours of injury
  • Preferred agent
    • Phenytoin (15-20mg/Kg) has been found to decrease seizure incidence within 7 days
    • Keppra has been shown to be non-inferior to phenytoin in 1 trial
  • Specific pathology
    • Sub Dural Hematoma (SDH)
      • 3% will seize
      • 25% seize after surgery/clot evacuation
      • Risk factors for seizure
        • Isolated SDH
        • Craniotomy
        • Lower GCS
      • Phenytoin or Keppra recommended
    • Sub Arachnoid Hemorrhage (SAH)
      • 26% will seize
      • Risk factors for seizure
        • Aneurysm in MCA
        • Thickness of clot / amount of bleeding
        • Associated intracranial hemorrhage (ICH)
        • Rebleeding
        • Infarction
        • Lower GCS
      • Though seizures are more common in SAH, Retrospective studies have shown no benefit of AEDs in reducing seizure occurrence
      • Off label use for seizure prophylaxis with Keppra is still sometimes performed
    • Intracranial Hemorrhage (ICH)
      • Prophylaxis not recommended / not found to be beneficial
      • If seizures, treat according to protocol above

AED Monitoring

  • Indications for monitoring (Checking a level)
    • Outpatient management
      • Narrow therapeutic range
      • Initiation of therapy
      • Seizures persist despite adequate dosing
      • Suspected alterations in metabolism (Pregnancy, renal failure, drug interaction, etc.)
    • Emergency management
      • Suspected toxicity
      • Suspected non-compliance
  • Utility of drawing levels in the ED
    • Most will be largely inaccurate
    • Recommendation is to draw this labs at their trough, which isn't always possible in the ED
    • Ultimately, we are trying to determine 1 of 2 things:
      • Toxicity:  If it's toxic level that might explain clinical picture
      • Non-Compliance:  If their level is low, that might explain their presentation with seizure due to non-compliance/insufficient dosing
    • Things to keep in mind
      • It takes a while for many AEDs to reach steady state
      • If patient was just started on AED and levels are low, may not be due to non-compliance

QI/KT:  STEMI with Drs. Murphy-Crews and scanlon

Objectives:

  • Goal of QI/KT is to develop an evidence based algorithm for the diagnosis and/or management of a particular pathology
  • The goal of this lecture is to present an evidenced based algorithm for the management of STEMIs in the ED
  • Both primary evidence and guidelines from professional societies were reviewed

Review of Traditional MONA Treatments in STEMI:

MORPHINE: 

  • Background
    • Has been commonly used in STEMI / ACS for years
    • Benefits include
      • Adequate analgesia
      • Also helps with dyspnea
      • Treating pain helps abate catecholamine surge => Decreased demand
      • May also reduce venous congestion secondary to vasodilation
    • Use was called into question recently
      • CRUSADE Trial in 2005
        • Found that patients with NSTEMI treated with morphine had an odds ratio of 1.49 for mortality
        • However, may have had some selection bias as sicker patients may have required more pain control
      • IMPRESSIONS Trial in 2016
        • Suggested that morphine may delay uptake of oral anti-platelet agents
  • Recommendation
    • Morphine still recommended by AHA in pain that is refractory to nitroglycerine
    • Fentanyl may be safer alternative
      • Shorter half life
      • Shown to be non-inferior in RCT performed in 2016

OXYGEN:

  • Background 
    • Used for years as therapy in ACS and MI
    • Reasoning was that heart is not seeing enough oxygen, oxygen in theory should help
    • HOWEVER, Recent studies have shown that this is not the case
  • Several studies have demonstrated harm with superoxygenation in ACS
    • NEJM article in 2017 demonstrated no benefit in terms of death or readmission following MI
    • AVOID (2015):  Demonstrated increased infarct size at 6 months in patients who received oxygen
    • COCHRANE REVIEW (2013):  Normoxic patients treated with O2 had increased mortality with a RR of 2.11
    • Physiology
      • Found that excessive O2 leads to excessive free radical production and increased tissue death during ischemia
  • Recommendation
    • Supplemental O2 is not recommended in patients with O2 Saturation > 90%
    • Hypoxic patients should still receive supplemental O2 with goal of O2 Sat >90%

NITROGLYCERIN:

  • Background
    • In use for ACS since 1878
    • Physiology
      • Converted to NO
      • Creates cGMP
      • Leads to vasodilation
    • Very little evidence actually supporting its statistical benefit.  Seems to be largely accepted from anecdotal and historical use.
  • Evidence does show benefit in the hypertensive patient
    • IV formulation (Drip) has been shown to decrease mortality in hypertensive patients with ACS
    • Benefit is only seen when used in the first 24 hours
  • Recommendations
    • No evidence supporting its routine use
    • IV drip may be useful in pain refractory to fentanyl/morphine
    • Recommended in hypertensive patient with ACS

ASPIRIN / ANTI-PLATELET AGENTS / ANTICOAGULANTS:

  • ASPIRIN
    • Background
      • Inhibits platelet aggregation by blocking thromboxane-2
    • Several large studies showed significant mortality benefit for use in STEMI and ACS
      • ISIS-2
        • Showed mortality benefit of aspirin administration
        • NNT was as low as 42
    • Risk of bleeding was also low, with NNH of 167
    • Dosing evidence is not great
      • Common practice in US is to give 325mg
      • Practice in Europe is to give 160mg
      • Both appear to work
    • Recommendation
      • Recommend for use of full dose non-enteric coated aspirin, 324mg
  • OTHER ANTI-PLATELET AGENTS
    • P2Y12 Inhibitors
      • Common agents:
        • Clopidogrel (Plavix)
        • Ticagrelor (Brilinta)
        • Prasugrel (Effient)
      • Benefits in ACS / STEMI have been demonstrated
        • COMMIT (2005)
          • Demonstrated improvement in all cause mortality
          • NNT 167
        • CLARITY TIMI (2005)
          • Demonstrated improvement in perfusion during cath, with more frequent TIMI 3 flow following clopidogrel administration
      • Newer agents may actually be more efficacious
        • Ticagrelor and Prasugrel have been shown to have a mortality benefit over clopidogrel in patients undergoing PCI
        • Ticagrelor and Prasugrel have not been studied in patients undergoing thrombolysis
      • Recommendations
        • Recommend for the administration of Ticagrelor in patients with STEMI
        • Recommend for the administration of Clopidogrel in the setting of thrombolysis
    • GP IIb/IIIA inhibitors
      • Have not been shown to be beneficial over P2Y12 inhibitors
      • Have shown increased bleeding risk
      • May not be necessary in acute ED setting
  • ANTICOAGULATION
    • Agents that have been explored include:
      • Unfractionated Heparin (UFH)
      • Low Molecular Weight Heparin:  Enoxaparin (Lovenox)
      • Bivalrudin 
      • Fondiparinux
    • Recommendations for which anticoagulant to use can vary depending on the situation
      • Comparison of UFH and Bivalrudin
        • HEAT (2014) Demonstrated UFH was preferred over bivalrudin
      • Comparison of UFH and LMWH
        • Large Meta-analysis
        • Benefit to LMWH was seen in patients undergoing fibrinolysis
    • Recommendations
      • For patients undergoing PCI
        • UFH is recommended
        • Most cardiologists are familiar with it
        • The short half-life is appealing for people undergoing an invasive procedure
        • Low cost
      • For patients undergoing fibrinolysis
        • Despite studies showing possible superiority with LMWH, still recommend UFH
        • Reasoning is that most patients who undergo lysis will still likely undergo a subsequent catheterization

BETA BLOCKERS

  • Background
    • Theoretically reduces ischemia during MI by decreasing demand (Lower HR, decreased afterload, etc)
    • Initial data in the 1980s showed a mortality benefit, however there are some problems with interpreting the data
      • Performed at a time when PCI / re-perfusion was not regularly performed
      • Did not address route, no info on timing
      • Compared a number of treatment regimens that weren't equivalent
  • More recent data shows they can be detrimental in STEMI (within 1st 24 hours)
    • GRACE (2014) demonstrated a higher mortality in patients who received early B Blocker therapy (Within first 24 hours)
    • SWEDEHART Trial demonstrated that use of IV beta blockers led to an increase in mortality
  • Recent studies show no immediate benefit.  However, long term they may help mitigate risk (post-intervention)
  • Recommendations
    • Algorithm recommends against the use of beta blockers in acute STEMI

Percutaneous Coronary Intervention (PCI) Vs. Thrombolysis

Thrombolysis:

  • Data supporting its use
    • GISSI1:  Streptokinase Vs. Placebo
      • Showed significant benefit to lysis with streptokinase vs. placebo
      • NNT was 13.9 in the less than 1 hour group
      • NNT was 41.6 in the 3-6 hour group
      • No difference past 6 hours
    • Newer thrombolytic agents have since been released:  
      • ASSESNT 2 Compared different thrombolytic agents
        • Found less bleeding complications with Tenecteplase

PCI:

  • Keeley, Boura, Grines et al. 
    • Meta-analysis
    • Compared thrombolytics vs. PCI
    • PCI substantially better than lytics alone
  • Comparison of PCI vs. lytics at different time frames
    • CAPTIM trial:  Found that benefit of PCI over lytics waned at 60-120 minutes
    • AHA set hard limit at 120 minutes
  • Recommendation
    • If patient can make it to balloon within 120 minutes, PCI is better option
    • If not, lytics
    • ALL patients who receive lytics should still be transferred to cath capable hospital as most receive cath

COMBINED PEDIATRICS LECTURE:  THE PALE CHILD With Dr. Kevin Overmann

Objectives:

  • Recognize pathological pallor
  • Formulate cognitive strata for differential diagnosis
  • Identify the life threatening / emergent conditions
  • Create framework for evaluation and referral

Pallor in a child - Causes

  • Important to consider alternative causes of pallor (Not anemia)
    • Physiologic
      • Is the child always pale?
      • Trust parents opinion
    • Shock
    • Respiratory distress / dysfunction
    • Hypoglycemia
    • Skin edema
    • Pheochromocytoma
  • Anemia
    • Definition of anemia in children
      • Levels of hemoglobin and hematocrit change with age
        • 22 - 42 weeks gestational age
          • Iron stores are high from mother
          • Accumulated largely in 3rd trimester
            • ***Premature infants at risk for anemia, because they miss this iron accumulation***
          • Hb may range from 13-17
        • 1 Month to 1 year
          • Precipitous drop in Hb initially
          • No longer have maternal source of iron
          • Nadir around 2 months old
          • Average Hb around 11
    • Approach to anemia:  Consider 3 broad categories
      • Production
      • Destruction
      • Blood Loss
    • Production
      • Congenital Abnormalities
        • Thalassemias
        • Diamond Blackfan Anemia
          • Progressive severe anemia
          • Occurs in the 1st year of life
          • Associated abnormalities
            • Thumb abnormalities (20%)
            • Short stature (47%)
            • Congenital heart disease (15%)
              • VSD
              • ASD
              • Coarctation
            • Maxillofacial abnormalities (10%)
            • Other
          • Diagnosis
            • Elevated erythrocyte adenosine deaminase
            • Bone marrow biopsy
            • Genetic testing
          • Management
            • Steroid taper
            • Usually deferred until 6 months
            • Transfusion as needed
        • Fanconi Anemia
          • Inherited defect in DNA repair
          • Loss of hematopoetic stem cells
          • Leads to pancytopenia
          • Associated with several congenital malformations
            • Short stature
            • Abnormal thumbs/radii
            • Pigmentation
            • Microcephaly
          • Associated with:
            • Hematologic malignancies
            • Carcinomas
        • Disordered erythroid maturation:  sideroblastic anemia
      • Acquired Insults
        • Transient Erythroblastopenia of Childhood
          • Background
            • Unknown incidence (Roughly 4/100,000?)
            • Unknown etiology
              • Viral infection?
              • Environmental factors
              • Sibling cases reported, which makes viral or environmental more likely
          • Highest incidence 18-24 months
          • Findings
            • Exam: 
              • Pallor
              • Otherwise often normal
              • No organomegaly
            • Laboratory evaluation
              • Anemia (Normocytic, normochromic)
              • Reticulocytopenia
              • MCV increases with recovery
          • Management
            • RBC transfusion for symptomatic relief only
            • No indications for steroids or IVIG
            • 80% resolve spontaneously in 1-2 months
            • May take up to a year
            • No long term sequelae
        • Nutritional deficiencies
          • Iron deficiency anemia
            • Background
              • Most common nutritional deficiency worldwide
              • 9.2% toddlers are iron deficient
              • 2.1% have iron deficiency anemia
            • Cause:
              • Largely secondary to poor dietary intake
              • Cow's mild in US diet is large contributor
                • Low iron bioavailability
                • Sub-clinical GI bleeding
                • Displaces other iron rich foods in diet
            • Symptoms
              • Fatigue
              • Headache
              • Dyspnea
              • Pallor
              • Pica
              • Poor appetite
              • Edema
              • Developmental regression
              • Cardiomyopathy
            • Major concerns
              • Poor long term developmental outcomes
          • Lead toxicity
            • Commonly affects
              • Children < 5 (Tend to explore the world with their mouth)
              • Patients of lower socioeconomic status
            • Major concern is poor neurologic outcome
          • Folic Acid
          • B12
          • Hypoplastic events
            • Aplastic anemia
              • Etiology
                • 80% idiopathic
                • 9% Post hepatitis
                • 7% Viral
                • 4% Toxin
              • Symptoms / Findings
                • Anemia =>  Pallor, fatigue
                • Thrombocytopenia =>  Bruising, bleeding, epistaxis, menorrhagia
                • Neutropenia =>  Fever, focal infection
                • Absent Lymphadenopathy
                • Absent Splenomegaly
              • Management
                • Withdraw offending agent (If present)
                • Prompt evaluation
                • Empiric antibiotics should be considered
                • Selective transfusion
                  • HOWEVER
                  • Many may be candidates for bone marrow transplant from siblings
                  • Transfusion may limit success
                  • Use very selectively
            • Drug reaction
            • Infection
          • Abnormal synthesis
            • Lead toxicity
            • Anemia of chronic disease
    • Destruction
      • Congenital Abnormalities
        • RBC membrane defects:  Spherocytosis, elliptocytosis, paroxysmal nocturnal hematuria
        • Hemoglobinopathies:  Sickle Cell Syndromes
        • Enzyme Defects:  G6PD, Pyruvate Kinase Deficiency
      • Acquired Insults
        • Immune hemolytic anemias
        • Microangiopathic anemia:  DIC, Hemolytic uremic syndrome, cavernous hemangioma
          • Hemolytic Uremic Syndrome (HUS)
            • Epidemiology
              • Usually in patients < 5 years old
              • Usually in summer months
            • Cause: 
              • 90% related to infection with Shiga toxin producing E. Coli
              • 5-15% related to pneumococcal infection
            • Findings
              • Anemia (And associated symptoms)
              • Usually accompanied by belly pain, sequelae from E. Coli infection
              • Labs
                • Renal diseases is major complication (Decreased creatinine clearance, GFR)
                • Anemia
                • Signs of hemolysis
            • Management
              • Aggressive fluid resuscitation
              • Transfusion for Hb < 6
              • No antibiotics (Do not want to lyse cells => increased toxin release)
        • Abnormal synthesis:  Lead toxicity, anemia of chronic disease
    • Blood Loss
      • Trauma
      • Post operative
      • Atraumatic
        • GI:  Lesions, varices, colitis, milk allergy
        • Gyn:  Ectopic, menorrhagia
        • Renal:  Hematuria
        • Vascular:  AVM
        • Splenic sequestration
          • Background
            • Commonly occurs in patients with sickle cell disease
            • Often before 5 yo, prior to splenic fibrosis
            • High mortality associated with it
          • Symptoms
            • LUQ pain
            • Splenomegaly
            • Pallor
            • Lethargy
          • Management
            • Supportive care
            • Fluid resuscitation
              • Crystalloid initially to stabilize perfusion
              • Transfusion
                • Following crisis, many RBCs return to circulation
                • Risk of over-circulation
            • Usually resolves over the course of days

Evaluation / Management of the Anemic Child

  • History
    • Developmental history to screen for possible congenital cause
    • Social history
    • Dietary history (Nutritional deficiencies)
  • Diagnositics
    • CBC with Diff
    • Smear (Assess for hemolysis, abnormal morphology, counts, etc)
    • Reticulocyte count (Assess for aplastic anemia)
    • Ancillary studies depending on leading suspicion
  • Management
    • Transfusion in pediatrics
      • Paucity of data
      • Varying practice patterns
      • Should be done with caution
        • PRISMIII
          • Odds ratio of death higher in children who receive transfusion
          • Odds ratio for issues with cardiac/respiratory function increased
        • Risk of mortality independently associated with increased mortality
      • Recommendation
        • Start low, go slow!
        • 3-5mg/kg over 4 hours
        • Continue with slow alloquots if need be
        • Consider whether or not the patient would be a candidate for hematopoetic stem cell transplant - may change decision to transfuse

R4 CASE FOLLOW UP:  B PoD BONANZA! With Dr. Nicholas Ludmer

CONCEPT

  • The demographics are fake, but the cases are real.  Each one with clinical pearl!

B21:  Middle aged female with sore throat

  • De Quervain's Thyroiditis  (Subacute Granulomatous Thyroiditis)
    • Etiology:
      • Unkown
      • Thought to likely result from viral infection
    • Diagnosis:
      • History
        • Rule out other possible causes of painful thyroiditis
          • Radiation
          • Trauma
          • Post Partum  (Usually painless)
          • Drugs  (Usually painless)
      • Largely clinical
        • 1-2 weeks of pain around thyroid
        • Initial symptoms of hyperthyroid as thyroid destruction => release of thyroid hormone
        • Followed by symptoms of hypothyroid => Period of decreased production/recovery
      • Laboratory evaluation
        • TSH
          • Initially low (Increased thyroid hormone release 2/2 follicle destruction => negative feedback)
          • High later on in course  (Decreased thyroid hormone => Increased TSH)
        • ESR/CRP often elevated
      • Imaging
        • Ultrasound is important to rule out abscess

B22:  Elderly male with new onset seizure

  • Diagnosis:  Aortic Dissection!
    • Management:
      • BP and Heart rate management
      • Goal of HR <60 BPM
      • Goal of SBP < 100-110
      • However, should really titrate to clinical picture
    • Medications
      • Beta blockers preferred
        • Esmolol Drip
        • Repeated labetolol dosing also acceptable
      • Calcium channel blocker can be added for additional BP management if BB insufficient

B23:  Elderly female with body aches

  • Diagnosis:  Polymyositis
    • Symptoms
      • Proximal muscle weakness
      • Painful muscles 2/2 muscle breakdown
    • Evaluation
      • Elevated total CK
      • Mildly elevated ESR
    • Management
      • Steroids
    • Learning point
      • Polymyalgia Rheumatica may present similarly with pain and "weakness" in proximal muscles/joints
        • Usually does not involve muscle breakdown  (CK will be low, normal)
        • Polymyalgia rheumatica associated with significantly elevated ESR (Usually > 100)

B24: Middle aged female who presented with oral pain

  • Diagnosis:  Palatal ulcer
    • Differential
      • Trauma
        • Usually diagnosed on history / Exam
      • Congenital (Cleft palate)
        • History is key
        • Check for other signs of congenital abnormality (cleft lip, etc)
      • Malignancy (Squamous cell, verrucous carcinoma)
        • Smoking/alcohol history
        • History of B symptoms
          • Weight loss
          • Night sweats
          • Progressive
          • Lymphadenopathy
      • Infectious (Mucormycosis)
        • Usually affects immunosuppressed patients
      • Inflammatory  (Crohn's)
        • Ulcers are usually red, beefy
        • Located often on gingiva, but can be anywhere
        • Not always midline
      • Tox (Cocaine)
    • Midline central ulcer of soft palate most consistent with cocaine use

B25:  Elderly male with facial trauma

  • Diagnosis:  E-cigarrette explosion
  • Learning point:
    • E Cigarrettes are a growing industry
    • Largely unregulated
    • Poor battery manufacturing makes explosion possibility
    • Nicotine poisoning also common among children, as liquid is usually flavored/sweet smelling

B26:  Young male with fatigue/nausea/vomiting

  • Diagnosis:  Graves Disease with Thyroid storm
    • Diagnosis of thyroid storm
      • Clinical Diagnosis
      • Common Symptoms
        • Fever (Usually high > 102)
        • AMS is common
        • Arrhythmia, tachycardia
        • GI dysfunction:  nausea, vomiting, abdominal pain
      • Burch Wartofsky Scoring System helps with diagnosis 
        • Scoring system based on symptoms
        • Score >45 Highly indicative of thyroid storm
    • Management
      • Stop production of thyroid hormone
        • Propyl Thyouracil (PTU)
          • Preferred agent
          • Stops production and peripheral conversion
          • HOWEVER, not available IV if patient is unable to take PO
        • Methimazole
      • Block Release
        • Lugol's Solution:  Iodine solution
          • Overwhelming thyroid with iodine stops production and release
          • Called "Wolf Chaikoff" effect
          • DO NOT GIVE BEFORE PTU or METHIMAZOLE
        • Lithium can also be used
      • Block peripheral effect
        • Usually focuses on blocking adrenergic stimulus
        • Beta blockers
          • Propranolol preferred
            • Blocks peripheral conversion in addition to adrenergic receptors
          • Esmolol can also be used

B27: Young female with difficulty swallowing

  • Diagnosis:  Food-derived botulism
    • Differential for bulbar weakness
      • Myesthenia gravis
      • Guillain Barre:  Miller Fischer Variant
      • Stroke
      • Infection: Polio, Lyme disease
      • ALS
      • Tumor
    • Diagnosis
      • Largely based on history
        • Honey
        • Canned foods
      • Laboratory testing for toxin does exist
  • Management
    • Report to CDC
    • CDC can release antitoxin
    • Supportive care
      • Will likely need airway management

B28:  Middle aged female with shortness of breath

  • Diagnosis:  Pulmonary endometriosis
    • Endometriosis of the thorax is rare, but possible
    • Characterized with chest pain and SOB monthly
  • Management:
    • Medical management
      • Hormonal therapy
    • Surgical management
      • Removal of tissue/implantation site

B29:  Elderly male with chest pain

  • Diagnosis:  Esophageal adenocarcinoma
  • Learning point
    • Not all chest pain is ACS
    • Do not anchor on referral diagnosis

B30:  Elderly male with sore throat

STEMI.png
  • Diagnosis:  STEMI
    • Very atypical presentation of ACS
    • Learning point
      • Classic definition of ischemic pain and ACS does not apply to / capture all patient populations
      • Patients likely to present without classic symptoms
        • Elderly
        • African Americans
        • Women
        • Diabetic patients
      • Many may present with respiratory or abdominal symptoms 

B31:  Elderly male with suicidal thoughts

  • Diagnosis:  TCA overdose
    • Presentation
      • Anticholinergic toxidrome
      • Initial adrenergic surge, followed by washout/refractory shock
      • Arrhythmia secondary to sodium channel blockade
    • EKG findings
      • QRS widening
      • Prolonged QRS
      • RSR' pattern in AVR
    • Management
      • Sodium Bicarbonate
        • Sodium helps correct arrhythmia
        • Bicarbonate/alkalynization helps keep TCA protein bound in periphery
        • Helps correct profound metabolic acidosis
      • Hypertonic can also be used to treat arrhythmia, but does not address acidosis
      • Supportive care
        • Most will require intubation:  Best to intubate early to avoid intubation during severe acidosis.
        • Hemodynamics
          • Fluid resuscitation
          • Pressors if needed

R1 CLINICAL DIAGNOSTICS:  Vaginal bleeding with dr. Sim Mand

Disclaimer:  Will not discuss vaginal bleeding in the pregnant patient

Definitions:

  • Abnormal Uterine Bleeding (AUB):  May be acute or chronic and is defined as bleeding from the uterine corpus that is abnormal in regularity, volume, frequency, or duration and occurs in the non-pregnant patient (ACOG)

Differential:  PALM COIEN

  • Sturctural
    • P:  Polyps
    • A:  Adenomyosis
    • L:  Leiomyoma (Fibroids)
    • M:  Malignancy/Hyperplasia
  • Miscellaneous
    • C:  Coagulopathy
    • O:  Ovulatory Dysfunction
    • I:  Iatrogenic
    • E:  Endometrial
    • N:  NOS
  • Most Common By Age Group
    • 13-18 years old
      • Coagulopathy (Von Willebrand's Disease most common)
      • Ovulatory Dysfunction
    • 30-40 years old
      • Structural Etiologies
        • Polyps
        • Fibroids (Common in African American population)
        • Adenomyosis
    • >45 years old
      • Hyperplasia and malignancy

Assessment

  • History
    • Severity
      • Heavy blood loss
        • Greater than 1 pad/Hour
        • >80cc's total
      • Pictorial blood loss charts also available
    • Timing
      • On cycle vs. off cycle
      • Duration
    • Other symptoms
      • Fevers/chills
      • GI symptoms
    • Also important to ask
      • Contraceptive history
      • Previous gestational history
      • Previous medical and surgical history
      • Fertility goals
  • Exam
    • Pelvic exam
      • Assess for external causes of bleeding
      • Assess if cervix is closed
      • Assess for adnexal and uterine masses with bimanual exam
  • Laboratory evaluation
    • Depends on clinical presentation
      • Everyone:
        • Pregnancy test
        • CBC
        • Type and screen
      • Systemic disease
        • Renal panel
        • LFTs
      • If concern for bleeding diathesis/coagulopathy
        • PT/INR
        • PTT
        • Fibrinogen
        • vW factor antigen
        • Ristocetin cofactor assay
        • Factor VIII
        • ***Many may not come back in the ED, but will facilitate follow up***
      • If concern for endocrinopathy
        • TSH
        • Free T4

Management:

  • Stable Patient
    • Acute bleeding
      • If sufficient concern /  level of bleeding
      • May start hormonal therapy in ED
      • Most common oral contraceptives acceptable
        • Usually a tapered course
          • Mild bleeding:  BID
          • Moderate bleeding:  QID
      • TXA also an option
      • Gynecology referral
    • Chronic bleeding (Symptoms > 3 months)
      • Goal is to prevent further episodes
      • Therapy
        • Hormonal contraceptives
          • Combined estrogen/progesterone
          • DO NOT USE ESTROGEN ONLY CONTRACEPTIVES LONG TERM
        • NSAIDS
        • TXA
          • 1.3g TID
          • No evidence of increased thromboembolic risk
      • Gynecology referral
  • Unstable Patient
    • CONTACT GYN EARLY
    • Resuscitation
      • Can use crystalloid initially
      • Will likely require transfusion
    • Uterine tamponade
      • 30cc foley balloon
      • Pack the uterus
    • Hormonal therapy
      • IV Estrogen (25mg IV q4-6 hours)
      • Give with anti-emetic
      • Consider heparin for DVT prophylaxis