Grand Rounds Summary 9.6.17

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Consultant of the Month - Second and Third Trimester Common Complaints: Dr. McKinney from Maternal Fetal Medicine

Physiologic Changes in Pregnancy:

  • Uterus. Increases in size from 70 grams in the non-pregnant state up to 1100 grams.
  • Cervix. Cervical ectropion occurs during pregnancy placing pregnant women at higher risk for post-coital bleeding and Trichmoniasis infection.
  • Vagina. Increased vaginal secretions can occur as well as changes in vaginal color.
  • Skin. There are many skin changes that occur such as stretch marks, hyperpigmentation, linea nigra, and cholasma (mask of pregnancy).
  • Breast. Women begin to produce colostrum in the second trimester. 
  • Weight.  Average weight gain in pregnancy is 12.5kg.
  • Water metabolism. There is a decrease in plasma osmolality by 10 mOsm/kg causing increased water retention contributing to a state of chronic volume overload.
  • Hematology.  Anemia and thrombocytopenia occur due hemodilution because of increased plasma volume. Pregnant women have a 5-6 fold increased risk in venous thrombombolism due to an increase in procoagulant factors and decrease in fibrinolytic activity.
  • Cardiac. The heart is displaced up and to the left within the chest. EKG may show a left axis deviation. On physical exam a systolic murmur is very common. There is increased cardiac output as well as decreased blood pressure due to decreased in systemic vascular resistance in pregnancy.
  • Pulmonary. There is increased tidal volume and minute ventilation due to increased progesterone causing a compensated respiratory alkalosis. Normal ABG ranges in pregnancy are pH 7.4-7.45, PaCO2 27-32, and PaO2 >100. 
  • GI. GERD is common due to excess progesterone relaxaing the LES.

Urgent Vaginal Bleeding in the Second and Third Trimester of Pregnancy

Placental abruption- separation of the placenta from the uterus, 80% have vaginal bleeding

  • Risk factors: cocaine, smoking, rapid uterine decompression
  • Labs: CBC, coags, T&S, DIC labs, TEG
  • Management: Resuscitation! 1:1 (pRBCs and plasma) and cryo to correct for fibrinogen. Goal resuscitation markers are Hb >7, PLT >20, fibrinogen >100k 

Placenta Previa - the placenta is covering the cervix, classically "painless vaginal bleeding" however in Dr. McKinney's experience this is not the case as the bleeding can irritate the uterus causing contractions

  • Risk factors: history of cesarean delivery as these patients are also at high risk for placenta accreta
  • Labs: CBC, T&S, coags, fibrinogen, KB
  • Management: tocolysis and prompt delivery by cesarian section

Vasa Previa - fetal blood vessels travel within the membranes and cross the internal cervical os

  • Management: AVOID THE DIGITAL EXAM and delivery by cesarian section

Morbidly Adherent Placenta - abnormal placenta implantation 

  • Management: prepare the patient for the OR, DO NOT try to remove the placenta and transfer the patient is a level III/IV maternal hospital

Uterine Rupture - when the integrity of the myometrial wall is disrupted, most commonly at the site of a previous surgery

  • Management: needs surgical correction 

Postpartum Hemorrhage - >500mL after vaginal delivery, >1000mL after Cesarean delivery, most common cause of maternal mortality worldwide

  • Risk factor: precipitous birth
  • Etiologies: uterine atony, laceration, coagulopathy, retained placenta, uterine rupture
  • Management: bimanual massage, pitocin, methergine, hemabate, misoprostol, uterine tamponade with either packing or a balloon

Labor/Preterm Labor Evaluation

Term: >37 weeks
Preterm: <37 weeks
Periviable: 22-24 weeks

  • History: vaginal bleeding, loss of fluid, fetal movement, gestational age, pregnancy complications, past pregnancies
  • Physical Exam: fundal height, tenderness, speculum exam, digital exam- unless you are concerned for placenta or vasa previa
  • Labs: CBC, T&S, UA
  • US: fetal presentation 
  • Management: if know GBS positive (or preterm) give penicillin. If penicillin allergy can give ancef of if the patient is anaphalytic to penicillin than give vancomycin. Consider giving betamethasone if less than 34 weeks gestation for lung maturity. In the setting of preterm labor you can consider tocolysis

Chorioamnionitis

  • Infection involving the amniotic cavity and the chorioamniotic membranes
  • Sx: fever plus maternal tacyhcardia, fetal tachycardia, fundal tenderness, or vaginal discharge
  • Management: amp/gent or zosyn, delivery

Appendicitis in Pregnancy

  • Appendix moves cranially as pregnancy progresses from its pre-pregnancy location

Premature Rupture of Membranes

  • Management: steroids if <34 weeks, tocolysis <34 weeks, antibiotics - azithromycin and amoxicillin, if over 34 weeks then delivery is indicated

Decreased Fetal Movement

  • Fetal HR, even if normal is not reassuring, will need additional testing preformed by L&D. These patients should not be discharged from the ED.

r3 small groups: Minor Care Procedures with drs. murphy, mckee, liebman and whitford

Measuring Compartment Pressures

Compartment syndrome is due to increased pressure in a close, non-expandable space. Often caused by fracture, IV extravasation, burns, splints, snake bites, or excessive exertion.

6 P's of compartment syndrome:

  1. Pain
  2. Paresthesias
  3. Pallor
  4. Paralysis
  5. Poikilothermia
  6. Pulseless

Checking Compartment Pressures video here

Extensor Tendon Repair

  

  • Dorsum of the hand broken into various zones to help with description and injury considerations
  • Each digit has an extensor tendon formed by the extensor digitorum muscle.  However, the index and pinky finger have an additional tendon.  This may mask injury as the additional tendon may partially compensate.
  • Tendons in the dorsum of the hand are connected by a network of fibers called the juncturae tendinae.  This network may mask injury as an adjacent tendon can partially compensate.

Exam:

  • Isolate every joint to ensure each tendon is intact
  • Modified Elson’s test: can help identify central slip injury
  • Hyperextension Test: flatten hand on flat surface and extend fingers.  Look for asymmetry among the fingers.  This can identify injuries masked by the juncturae tendinae.

Management:

  • Injuries are either open or closed, depending on the presence of a skin defect

Closed Injuries

  • Splint in a volar extension splint, follow up with hand surgery within a week

Open Injuries:

  • Zone 1: This is a mallet finger.  The is treated with continuous extension splinting of the DIP joint and referral to a hand surgeon for follow up
  • Zone 2-4: These may be repaired in the ED
  • Zone 5: May potentially be a human bite from a clenched fist hitting a person’s teeth.  Refer for delayed repair by hand surgeon unless injury caused by sharp, clean object.
  • Zone 6: May be repaired in ED
  • Zone 7-8: The extensor retinaculum is in this area, this increases risk of adhesion formation.  Refer to a hand surgeon for repair.

Partial tendon lacerations that are <50% of tendon do not need to be repaired and require only splinting.  Partial tendon lacerations that are >50% of tendon are treated as a complete laceration and repaired.

Hip Ultrasound and Arthrocentesis

Can be used to identify effusions using the linear or curvilinear probe. First find the femoral vessels than move the probe laterally and caudally to find the femoral neck. When doing this the probe will have to be angled with the indicator pointing towards the umbilicus. It can be helpful to have the patient externally rotate their leg. To measure an effusion you want to measure the distance between the anterior layer of the effusion and the femoral neck. A joint effusion is diagnosed when there is a hypoechoic or anechoic fluid collection measuring >7mm or a difference between the hips is greater than 1mm. 

R1 Clinical Diagnostics: Soft Tissue Neck Films with Dr. Hughes

See Dr. Hughes's post here as a primer

Soft tissue XR - 79% of positive finding are missed by EM Physicians 

Case 1: 
10 year old with 3 weeks of cough, normal vitals and breath sounds
Dx: Suprahyoid foreign body
Most common reason to order a soft tissue neck film in the ED
Look suprahyoid and at C6 which is the level of UES (common place for food bolus)
On frontal view if a foreign body looks like a circle/coronal it's likely in the esophagus versus if it looks like slit it's likely in the trachea
Indirect signs of FB:

  • Shadow
  • Esophageal air
  • Loss of cervical lordosis
  • Neck emphysema

Pro-tip: If kid may have ingested something and you don't know if it's radiodense you can put it on their shoulder for the film to evaluate the object's radiodensity 

Case 2: 
45 year old male smoker presents with sore throat x 5 days. Started on amox by PCP. +Dysphagia and dysphonia. 
HR 110 RR 22 O2 95% 
Tenderness over the trachea and mild stridor
CXR Normal, WBC 13k
Dx: Epiglottitis

X-Ray findings:

  • Thumbprint signs (Sp 100, Sn 65.9)
  • Valecula signs (Sp 100, Sn 53.9)
  • Epiglottis width > 6.3mm (Sp 97.8, Sns 75.8)

Recent antibiotic use is an indecent risk factor for a false negative x-ray
Take away: neck xrays are specific but not sensitive enough to exclude epiglottis

Case 3:
7 year old boy with fever and neck stiffness who is febrile and tachycardic. He was diagnosed with influenza two days ago but now has worsening neck pain and continued fever.
Anterior cervical lymphadenopathy with no meningismus, tonsilar erythema, no tirsmus, no drooling
LP is unremarkable
Dx: RPA with widening of the prevertebral space
What makes an adequate film?

  • Adequate film: neck in full extension at the end of inspiration, need to see the C7-T1 junction

Ratios for assessing pre-vertebral space:

  • C2-C4 >1/2
  • C5-C7 > 1

Clinicopathologic Conference with Drs. Scanlon and Doerning

HPI: The patient is a female in her 30s G3P3003 with pmhx of gestational diabetes who complains of RUQ pain three hours after delivering a term infant via spontaneous vaginal delivery. Prior to delivery, the patient was induced with pitocin due to persistent mild range blood pressures and received a single dose of hydralazine and magnesium for one recording of a severe-range blood pressure prior to induction of labor. Delivery was otherwise uncomplicated. 

Vitals: BP 148/84 T 36.5 P 82 RR 18 O2: 99%

Physical Exam: Significant for mild tachypnea and grunting, mildly tender abdomen to palpation, no hepatosplenomegaly, no bruising or discoloration, no edema, +1 reflexes, firm uterus

Labs: BMP and CBC are within normal limits. These labs were drawn prior to delivery.

Differential Diagnosis

OB causes: uterine atony, uterine rupture, chorioamnionitis/endometritis, amniotic fluid embolism, pre-eclampsia/HELLP

Non-OB causes: acute appendicitis, cholelithiasis or cholecystitis, adenexal torsion/tumor/cyst

Dr. Doerning's Diagnosis and Test: Pre-Eclampsia/HELLP and LFTs

Test of Choice: LFTs!

HELLP Syndrome (Hemolysis, Elevated Liver enzymes, and Low Platelet Count)

Tennessee criteria (in addition to SBP >140 or DBP >90):

  1. Evidence of microangiopathic hemolytic anemia
  2. Platelet count <100K
  3. Total Bili >1.2 mg/dL
  4. AST >2x upper limit of normal or >70U/L

Sequelae of HELLP

  1. DIC (21%)
  2. Placental abruption (16%)
  3. Rental failure (8%)
  4. Pulmonary edema (6%)
  5. Subcapsular liver hematoma (1%)
  6. Retinal detachment (1%)
  7. Fetal demise if untreated

Management: Delivery if >34 weeks and aggressive management of pre-eclampitic features if present

  • Hypertension: hydralazine, labetalol, nifedipine/nicardipine
  • Mag for seizures, 6 grams over 2 hours as the initial loading dose
  • No indication for steroids 

Patient Follow Up

The patient continued to complain of RUQ pain post-partum and became persistently hypertensive. CT imaging showed a subcapsular hematoma with active extravasation. The patient went to IR for embolization and ultimately did well.