Grand Rounds Recap 11.13.24
/
sports medicine grand rounds WITH dr. gawron
Team physicians deal with a variety of medical complaints, including sports-related injuries as well as non-traumatic concerns
Case 1: Clavicular Osteomyelitis
18-year-old female athele presented with a soccer injury but developed fevers, erythema, and warmth of the medial clavicle
Ultimately, after multiple MRIs, was found to have osteomyelitis of the medial clavicle and required resection
Case 2: Patellar Tendon Abscess
24-year-old male athlete presents right right knee pain and fevers, was found to have a patellar tendon abscess, ultimately continued to fever despite antibiotics and on systemic work-up was found to have a hepatic abscess. Further work-up was largely unrevealing to the ultimate cause
Case 3: Thoracic Outlet Syndrome
21-year-old male baseball player presented with right arm pain and swelling. Ultimately was found to have a right DVT related to thoracic outlet syndrome and underwent surgical decompression with a 1st rib resection
rabies prophylaxis WITH tim boswell, rn
Five people died from rabies in the United States in 2021, which was the most in a decade, including one person who had received (improper) post-exposure prophylaxis
92% of cases of rabies in the US involve wildlife species (racoons, bats, skunks, and foxes most commonly)
The incubation period for rabies can be >2 years
Post-Exposure Guidelines:
Wound Cleansing
Administration of HRIG (Human Rabies Immune Globulin)
HRIG gets injected into and around the wound itself
Provides immediate passive immunization with virus-neutralizing antibodies, passive immunity occurs immediately
HRIG should not be administered more than 7 days after possible rabies exposure
HRIG should not be administered if the patient has previously been vaccinated for rabies
Rabies Vaccination
Stimulates the body to produce virus-neutralizing antibodies (active immunization), kicks in within 7-10 days
Vaccine should be administered on the opposite side of the body if HRIG has been administered
Vaccine Timeline:
Days 0, 3, 7, and 14 for immunocompetent patients
Days 0, 3, 7, 14, and 28 for immunocompromised patients
r2 qi/kt: acetaminophen overdose WITH drs. gabor and knudsen-robbins
Acetaminophen overdose is quite prevalent and associated with high risk for significant morbidity/mortality
Tylenol produces a toxic metabolite called NAPQI when metabolized by the liver’s CYP450 system
NAC is the mainstay of treatment in Tylenol overdoses, as it replenishes glutathione and is almost 100% effective if given within 8 hours of ingestion
Acute Tylenol ingestion:
Activated charcoal should be considered if presenting within 2 hours of ingestion
Obtain an acetaminophen level around 4-hours post ingestion (or as soon as possible if presenting after the 4-hour mark) and use this level to apply to the Rumack-Matthew treatment nomogram
Give NAC if the Tylenol level is above the treatment line on the nomogram
NAC can be dosed orally or intravenously
IV: loading dose of 200 mg/kg over 4 hours followed by maintenance dose of 100 mg/kg over 16 hours
Oral: 140 mg/kg loading dose followed by 70 mg/kg maintenance dose q4h x16 hours
Pediatric and pregnant patients are treated using the same nomogram/algorithm
Extended-release Tylenol ingestion or co-ingestions with other substances (i.e. opiates or anticholinergics):
Use initial nomogram and treat if initial level is above the treatment line.
If initial Tylenol level is below the treatment line:
If initial Tylenol level is >10 ug/mL, obtain repeat levels at 4-hours and 8-hours and start NAC if levels are rising
No need for NAC if initial level is <10 ug/mL or Tylenol levels are decreasing
Unknown time of ingestion
Obtain Tylenol level and LFTs on presentation
Start NAC if Tylenol level is > 10 ug/mL or AST/ALT are abnormal
Start NAC empirically if there is concern for an ingestion >6g or >200 mg/kg
Chronic ingestion:
Chronic ingestion: >6g/day or >150 mg/kg/d for >24 hours OR >4g/day or >100 mg/kg/d for >48 hours with symptoms concerning for toxicity
If Tylenol level is >20 ug/mL or AST/ALT are abnormal, start NAC
Consider a single dose of fomepizole (15 mg/kg) for severe ingestions:
4 hour APAP level >600 ug/mL
6-hour APAP level >424 ug/mL
8-hour APAP level >300 ug/mL
Hemodialysis should be considered for patients with a single APAP level >700 ug/mL at any point
Your local poison control center should be consulted for these cases
landmark studies in emergency medicine WITH drs. fermann and kreitzer
Article One: Sensitivity of CT performed within 6 hours of onset of headache for diagnosis of SAH: Prospective Cohort Study (2011)
3,132 patients presenting to Emergency Departments in Canada between 2000-2009 with a non-traumatic headache with thunderclap symptomology (maximum intensity within one hour of onset)
All patients had a CTH ordered, LP was performed at the discretion of the treating physician
Patients were followed for 6 months to identify adverse outcomes or missed SAH
CTH within 6 hours of symptom onset was 100% sensitive and 100% specific for identification of SAH
Sensitivity decreased to 85% after 6 hours
Article Two: Subarachnoid haemrorhge in the emergency department: a prospective, observational, multicentre cohort study (2024)
3,663 patients presenting to Emergency Departments in the UK between 2020 and 2023 with a non-traumatic headache with thunderclap symptomology (maximum intensity within one hour of onset)
Examined whether these patients received CTH +/- LP and followed-up after 28 days
Validated non-contrast CTH within 6 hours for the diagnosis of SAH
This study found that CTH has high sensitivity up to 24 hours after symptom onset, though sensitivity is not 100%
Post-test probability of SAH after a negative non-contrast CTH estimated at 0.1%
Article Three: Computed Tomography of the Head before Lumbar Puncture in Adults with Suspected Meningitis (2001)
Prospective cohort observational study involving 301 patients at Yale between 1995 - 1999
Of patients with suspected meningitis, CT and LP were performed at the discretion of the treating physician
CTH known to cause delays in LPs and subsequently antibiotics by ~2 hours
Patients were followed-up over 6 months
Factors that were identified as suggesting need for a CTH prior to an LP were:
Age >60 years
Immunocompromised state
History of known CNS disease
Seizure within one week prior to presentation
Neurologic findings such as altered level of consciousness, gaze palsy, visual field defect, arm or leg drift, or altered speech
Article Four: Development of the Canadian Syncope Risk Score to predict serious adverse events after emergency department assessment of syncope (2016)
4,322 patients >16 years of ago presenting to the ED within 24 hours of a syncopal event
Prospective cohort study of 6 Canadian Emergency Departments
Excluded patients with LOC >5 minutes, altered mental status, seizure, trauma, intoxication, or language barrier
Looked to identify death or serious adverse event within 30 days, such as arrhythmia, MI, aortic dissection, PE, severe pulmonary HTN, SAH, ICH
They used their results to derive the Canadian Syncope Tool to predict which patients would be at risk for adverse outcomes
History of hypotension
SBP <90 or >180 mmHg
Elevated troponin
Abnormal QRS axis
QRS > 130 ms
Corrected QT interval >480 ms
Clinical gestalt: diagnosis of cardiac syncope in the ED
r4 discharge/transfer/treat WITH drs. haffner and wright
The number of psychiatric emergencies across the U.S., for both pediatric and adult populations, is markedly increasing
Decisions to place an involuntary psychiatric hold ("pink-slip") can be challenging but clinicians have good legal protection for "good faith" efforts
Traditional characterizations of SI as “active” or “passive” may not be predictive of suicide attempt and/or completion
Acute alcohol intoxication may contribute to transient suicidal ideation but is also an independent predictor of suicidality
Malingering is real (roughly 10% of psychiatric admissions), but so is true psychiatric disease with an often-overlapping population
pediatric lecture: neonatal emergencies WITH dr. vinet
NRP vs. PALS
Most hospitals have their own protocol for what age of life they transition from an NRP-based resuscitation algorithm to a PALS-based algorithm
Differences:
PALS initiates compressions with any loss of pulse, followed by airway and breathing. Compressions and ventilation occur at a ratio of 30 compressions to 2 breaths
NRP attempts 30 seconds of positive pressure ventilation first and then initiates compressions if HR remains <60 after 30 seconds of adequate ventilation. Compressions and ventilation occur at a ratio of 3 compressions to 1 breath
NRP focuses on umbilical vein cannulation (preferred) or IO for access
Neonatal Resuscitation:
Rapid assessment -> Dry, warm, stimulate, and suction -> breathing -> airway -> circulation
Expected SpO2 at birth is 60%, increased by 5% per minute after birthpoor r
HR >100 but labored breathing or cyanosis: Supplemental oxygen as needed, consider CPAP
HR <100 or apnea: PPV at a rate of 40-60 breaths/minute, FiO2 of 21-30%, and PEEP of 4-5
HR <60: PPV with 100% FiO2, intubate or place an LMA if not responding, and initiate chest compressions if not responding after 30 seconds of effective PPV
IV epinephrine 0.02 mg/kg (of 0.1 mg/mL concentration) q3-5 minutes
Consider volume expansion with NS, LR, or blood at a dose of 10 cc/kg if no response
Congenital Heart Disease
May be missed on prenatal scans and pulse ox screening at birth
Can present as poor feeding, respiratory distress, poor weight gain, and shock
May present acutely within the first two weeks of life after rapid decompensation from closing of the ductus arteriosus
Ductal Dependent: Hypoplastic left heart syndrome, tetralogy of Fallot, critical coarctation of the aorta, and interrupted aortic arch
Obtaining 4-extremity blood pressures, pre- and post-ductal SpO2, EKG, and CXR can be helpful during the initial assessment
Prostaglandin E should be initiated if there is a high suspicion for a ductal lesion
Dose: 0.05 mcg/kg/min
Does have a risk of apnea, consider advanced airway prior to transport if transporting on PGE
Neonatal Sepsis
Ampicillin + gentamicin are typical first-line antibiotics
Ceftazidime or cefepime are alternates to gentamicin
Vancomycin can be considered if there’s a high suspicion for MRSA, acyclovir can be used if there’s a high suspicion for herpetic infection
Neonatal Metabolic Crisis
Presents with lethargy, poor tone, fatigue, poor feeding, poor weight gain, vomiting, seizures, and refractory shock
Differential includes sepsis, congenital heart disease, pyloric stenosis, NAT, infantile botulism, acute gastroenteritis
Work-Up: Blood gas, lactate, CMP, Mg, Phos, CBC, ammonia, cortisol, insulin, c-peptide, GH, pyruvate, beta-hydroxybutyrate, carnitine, acylcarnitine, free fatty acids, UA, urine organic acids, urine reducing substances
If possible, try to obtain labs (or at least lactate, pyruvate, ammonia) prior to any IVF/dextrose to aid diagnosis
Treatment
Bolus: 10 cc/kg D5W or 5 cc/kg D10W
Avoid D25 or D50 in neonates, there is a real risk of extravasation and long-term morbidity related to this
Continuous: D10NS at 1.5-2x maintenance rate
