Grand Rounds Recap 5.22.19
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Visual Diagnosis Potpourri WITH VISITING PROFESSOR DR. THURMAN
Patient presents with sudden-onset eye pain. On exam, the cornea is hazy with a dilated pupil and conjunctival injection in the affected eye. Diagnosis: acute angle closure glaucoma. The treatment involves topical beta-blockers (timolol), pilocarpine, and acetazolamide.
Patient presents with a Battle’s sign and raccoon eyes on exam. This should prompt consideration for basilar skull fractures. Other findings to suggest this include CSF rhinorrhea which can be diagnosed with testing the glucose of the fluid.
Hydrofluoric acid burn: Has a propensity for occurring underneath the fingernails. The treatment involves calcium gluconate which can be made into a gel and applied over the wound.
Lacrimal duct laceration: needs to be evaluated by ophthalmology and may require surgical repair. This occurred from a dog bite and requires antibiotics for coverage of Pasteurella.
Patient presents with superficial partial thickness and full thickness burns to the abdomen. Remember the rule of nines and parkland formula for resuscitation of burn patients.
Full thickness burns are insensate and often appear waxy. The treatment requires a skin graft.
Corneal laceration with ruptured globe: requires surgical repair. Seidel sign can be seen on fluorescein exam. The ED management includes protection of the eye without applying pressure to the eye, elevate the head of bed, and tetanus prophylaxis. Anti-emetics are crucial to avoid a sudden increase in ICP that can worsen the injury.
Dermatomyositis: presents with a heliotrope rash around the eyes.
Pseudoaneurysm in the foot: Can be seen with Yin-yang or Pepsi sign on ultrasound.
Trousseau’s sign: Carpalpedal spasm with inflation of the blood pressure cuff. This suggests hypocalcemia. It is often seen with Chvostek’s sign, twitching of the cheek with percussion over the facial nerve.
Epi-pen injection to the digit: Treatment includes topical nitro paste or local injection of vasodilators (phentolamine).
Frostbite: The treatment involves rewarming the affected areas with 38-42 C water.
Uvulitis: Consider allergic and infectious causes. Angioedema of the uvula is called Quinke’s Disease.
Necrotizing fasciitis: Gas in the soft-tissues on x-ray. Source control is needed rapidly.
Sympathetic ophthalmia: occurs after some sort of trauma to an eye which exposes the body to intraocular contents. An autoimmune reaction then occurs and attacks the unaffected eye. The treatment is enucleation of the traumatized eye and systemic steroids.
Cullen’s sign: Periumbilical ecchymosis suggestive of retroperitoneal hemorrhage. Often co-exists with Grey-Turner sign.
Acute necrotizing ulcerative gingivitis (ANUG): Usually caused by fusobacterium.
Herpes labialis: Ulcerative lesions. Treatment is Acyclovir (can be topical for minor lesions).
Pyogenic granuloma: Often associated with pregnancy. Do not excise because they bleed significantly. Refer to dermatology.
Phlegmasia cerulea dolens: Should prompt consideration for significant DVT. See this post.
Erlichiosis: Tick-born illness. Often presents with hyponatremia and transaminitis.
Rust ring: Caused by a metallic foreign body exposed to the eye. In order to remove this, a burr drill is used, but this generally requires ophthalmology follow up to perform.
AC Separation: Can present with a visible deformity which is sometimes confused with a dislocation.
Flexor tenosynovitis: Remember Kanavel’s signs which suggest the diagnosis.
Corneal ulcer with hypopion: Ophthalmology consult and likely admission for Q1H antibiotic drops. Often caused by pseudomonas in contact-lens wearers.
Pit viper bite with fasciculations: Treatment includes Cro-fab for severe cases. The most important lab to obtain is coagulation studies because coagulopathy is common.
Testicular torsion: Note abnormal testicular lie on exam with a high-riding testicle that should suggest the diagnosis. Treat with emergent urology consultation. May try the “open book” method to attempt manual detorsion.
Orbital cellulitis: Can present with globe displacement. Most commonly occurs from direct extension from ethmoid sinusitis.
Shingles: Vesicular rash in a dermatomal distribution. Hutchinson sign present with a rash on the tip of the nose and ocular involvement. Treatment is anti-virals +/- steroids.
Mallet finger: Extensor tendon injury. Splint in slight extension.
Anal fissure: Treat with stool softeners and sitz baths.
Corneal burn: Topical antibiotics.
Iridodialysis: Presents with a teardrop pupil and disruption of the iris. Suggest open globe.
Erythema Nodosum: Inflammation of the subcutaneous fat.
Perianal strep: Perianal erythema. Treated the same as strep throat.
Levamisole: Often adulterates cocaine. Causes a vasculitis and can result in agranulocytosis.
Methemoglobinemia: Treat with methylene blue.
Erysipelas: Treat with Clindamycin.
Hot tub folliculitis: Caused by pseudomonas.
Inhalant abuse: Sniffing, huffing, and bagging are ways that people use inhalants to get high. Toluene is higher in metallic paint but is more deadly.
Acute thyrotoxicosis: Treatment includes propanolol, steroids, PTU/methimazole, and iodine.
Sister Mary Joseph nodule: Umbilical nodule suggestive of intra-abdominal malignancy.
Brown recluse spider bite: Causes loxoscelism. Presents with fever, erythroderma, and a “red, white, and blue” lesion.
Check out Dr. Thurman’s book, The Atlas of Emergency Medicine.
QI/KT: community acquired pneumonia WITH DRS. MAND AND MODI
Procalcitonin is an emerging diagnostic test that has shown some utility in the evaluation of patients with penumonia. There was a meta-analysis that showed a reduction in antibiotic use and side-effects in patients with acute respiratory infections when procalcitonin was used in the initial workup.1 Studies have shown that sputum cultures have many limitations and may not be entirely beneficial. However, they are inexpensive and can be useful in severe cases of pneumonia and may help tailor antibiotic choice. Blood cultures are increasingly positive in more severe cases but are likely unnecessary in uncomplicated cases with low Pneumonia Severity Index (PSI) scores.2 Realistically, it is difficult to predict a patient’s course based on their initial presentation, so blood cultures are still necessary prior to antibiotic administration in most patients.
Ultrasound is an increasingly popular diagnostic test that is useful in detecting patients with pneumonia. Dynamic air bronchograms are pathognomonic for pneumonia. Other features that suggest pneumonia include spine sign, hepatization of the lung, and unevenness of the pleural line. Lung ultrasound actually has been shown to have improved sensitivity when compared to x-ray. One meta-analysis found a pooled sensitivity of 92% and specificity of 93% (compared to 60-80% sensitivity for CXR).3 It does have some limitations that include difficulty diagnosing small consolidations and in areas with significant overlying subcutaneous tissue. This should be considered as an adjunct in patients with an equivocal CXR but concerning symptoms.
The treatment of pneumonia is complex and depends on a patient’s risk factors for drug resistance. Beta-lactams alone are not generally sufficient and should be combined with coverage of atypical organisms. One meta-analysis found that a beta-lactam (or cephalosporins) plus a macrolide was associated with lower short-term mortality in hospitalized patients with community acquired pneumonia.4 Fluoroquinolones can be utilized if no other options are available but should be avoided in elderly patients or those with recent steroid use because they have a higher risk for tendinopathy.
Healthcare-associated pneumonia is a term that is fading out but describes a cohort of patients who were thought to be at higher risk for multi-drug resistant organisms (MDRO). However, it appears to be a poor predictor of this cohort and is no longer recommended by the IDSA.5 Instead, certain risk factors seem to have a higher association with MDRO. These include previous antibiotic use in the past 90 days, previous MDRO colonization or infection, and structural lung disease.
Steroids have been shown to have a mortality benefit in patients with severe CAP and should be considered. The recommended dose is Methylprednisolone 40mg IV or Prednisone 40mg PO.
Several decision tools exist to help disposition patients with pneumonia including CURB-65 and PSI. SMART-COP is a newer decision tool that was created in Australia and helps determine patients who may require ICU admission.
Schuetz P, Wirz Y, Sager R, Christ-Crain M, et al. Effect of procalcitonin-guided antibiotic treatment on mortality in acute respiratory infections: a patient level meta-analysis. The Lancet, 2018; 18)1): 95-107.
Waterer G, Wunderink R. The influence of the severity of community-acquired pneumonia on the usefulness of blood cultures. Respir Med, 2001; 95(1): 78-82.
Orso D, Guglielmo N, Copetti R. Lung ultrasound in diagnosing pneumonia in the emergency department: a systematic review and meta-analysis. Eur J Emerg Med, 2018; 25(5): 312-321.
Lee J, Giesler D, Gellad W, Fine M. Antibiotic therapy for adults hospitalized with community-acquired pneumonia: a systematic review. JAMA, 2016; 315(5): 593-602.
Chalmers J, Rother C, Salih W, Ewig S. Healthcare-associated pneumonia does not accurately identify potentially resistant pathogens: a systematic review and meta-analysis. Clin Infect Dis, 2014; 58(3):330-339.
Chemical Burns WITH DR. WOLOCHATIUK
The identification of the causative agent is crucial in chemical burns because this can dictate the management. The time of contact with the chemical is associated with the extent of injury. Acid burns cause coagulation necrosis. Alkali burns cause liquefactive necrosis and often deeper penetration into the tissues. Management includes protection of healthcare workers, decontamination, and irrigation. The extent of the burn is often underestimated, and copious irrigation is necessary. Checking the pH of the skin until it is normal can help guide duration of irrigation.
Hydrofluoric acid should be treated with calcium. Hypocalcemia and hypomagnesemia are common electrolyte abnormalities seen with this exposure. Phenols are found in disinfectants, resins, and plastics. They are only moderately soluble in water, and the treatment requires polyethylene glycol (Miralax). Anhydrous ammonia can be inhaled and causes airway inflammation.
Ocular burns are more commonly seen in pediatrics than adults. Again, alkaline injuries are usually more severe. The treatment includes irrigation until the pH normalizes and analgesics. Ophthalmology is crucial because these often have long-term health implications.
Electrical injuries cause injury from the current itself, thermal injury, and potentially blunt trauma from an associated fall. These can have numerous clinical effects. Arrhythmias occur after 15% of electrical burns. Rhabdomyolysis and hypovolemia should be considered. Pupils may be fixed, dilated, or asymmetric without associated brain injury. Lichtenberg figures occur after lightning strikes. Keraunoparalysis is transient weakness that can occur after a lightning strike. For pulseless patients, CPR should be prolonged because many patients have good outcomes even after long periods of pulseless. Reverse triage should be considered in cases of multiple electrical burns, where providers should treat unresponsive/pulseless patients first.
The ED management of electrical injury includes EKG and telemetry monitoring. Some patients with have a troponin elevation and ischemic EKG changes that may be self-limited. Discussion with cardiology should be considered. Fluid resuscitation, burn management, and trauma evaluation is also warranted in the right clinical scenario.
CPC WITH DRS. LANE VS. LANG
Proctitis: The differential includes numerous infectious and non-infectious causes including sexually transmitted infections, malignancy, and inflammatory bowel disease. Lymphoma granuloma venereum (LGV) is re-emerging as a common cause of proctitis in men who have sex with men (MSM). In males with LGV proctitis, inguinal lymphadenopathy is less common due to the involvement of less superficial organs. Empiric therapy is with 21 days of doxycycline.
Taming the SRU WITH DR. VENTURA
Methemoglobinemia: Patients have excess ferric (Fe3+) iron and resultant decreased oxygen-carrying capacity in the blood. In addition, the oxygen binds tighter to the hemoglobin molecule due to a shift in the dissociation curve. This leads to significant hypoxia. Causes include numerous medications, list found here. Congenital methemoglobinemia is due to an enzyme deficiency or amino acid substitution. Such patients develop compensatory mechanisms to the hypoxia such as polycythemia. It can lead to chocolate-brown blood and hypoxia that is unresponsive to supplemental oxygen. The diagnosis is made on co-oximetry. The treatment is methylene blue for patients with methemoglobin levels >25% or those who are symptomatic. The dose is 1 mg/kg slow IV push. Response to treatment is judged based on symptoms. Refractory cases (typicially those with G6PD deficiency) may require exchange transfusion.
Exposure to industrial titanium powder: The management includes vacuuming the particles off the skin with the HEPA vacuum. Once the concentration of the powder is low enough, water irrigation can be safely used.
R4 Capstone WITH DR. SORIA
Temperatures are lowest in the morning and tend to be lower for elderly patients, so fevers are actually flexible and truly may be dependent on the patient in front of you. The size of the endotracheal tube matters and can have long-term consequences for patients.
