It’s difficult to miss a raging STEMI or a CVA with unilateral flaccid paralysis, but there are other, less-sexy diagnoses that we have the opportunity to make in the Emergency Department that can be as important and impactful to the patient’s health. Endophthalmitis is a difficult word to spell and equally as difficult to diagnose if you’re not looking for it. Check out Dave Traficante’s recent post on EM Resident on Endophthalmitis.
In the past, vitamin K and FFP were the mainstays of reversing warfarin, but now we have fancy new drugs like four-factor prothrombin complex concentrate (4F-PCCs). 4F-PCCs can rapidly reverse the INR of warfarin induced coagulopathy with less volume and quicker than FFP. Many of the dosing regimens base the dose on the patient’s presenting INR and body weight, with ranges from 25-50 IU/kg. A few problems arise with this approach, first the INR is not immediately available. Second, 4F-PCCs are not cheap; costing up to $7,000 per patient in some cases. Is there a fixed-dose regimen that we can give to patients on vitamin K antagonists without having to wait for the INR?
Some studies have looked at using 500 IU and 1000 IU fixed dose regimens for reversing the INR. The 500 IU only corrected the INR in 43% of the patients, whereas the 1000 IU fixed dose study showed better clinical outcomes in 83.5% of the patients, but there is concern that the obesity epidemic in the United States will dilute the IU/kg concentration of the 4F-PCC and not be as efficacious. Klein et al looked at using a fixed dose of 1500 IU of 4F-PCC for reversal of warfarin in 2015. It was a relatively small sample of 38 patients on warfarin with the vast majority of them presenting with an intracranial hemorrhage. Each patient had their INR drawn and then 1500 IU given before the result of the INR returned. 92.3% of the patients had their INR lowered to less than 2.0 after the 1500 IU of 4F-PCC and they reported no thrombotic events within the subsequent 7 days. The presenting INR median was 3.3 (2.5-4.0) which was reduced to 1.4 (1.2-1.6) after administration of the 4F-PCC. Additionally, this saved $40,273 dollars when compared to the typical INR and weight based dosing regimen for their patient sample.
We’ll have to figure out whether this fixed dose regimen of 1500 IU is the way to go, or should we base the dose solely on the patient’s weight and not worry about waiting on the INR. Does waiting the extra 20 minutes for the INR lead to improved clinical outcomes? And if we are going to start using a standard dose, is there a role for pre-hospital administration of the 4F-PCCs?
Post by: Terrance McGovern DO, MPH (@drtmcg13)
Lower abdominal pain in women can be challenging diagnostic dilemma in the Emergency Department. We had a case of a 50-year-old woman that had been previously seen by her PMD 3 days prior and diagnosed with a “small kidney stone” without any imaging, but did get the ever-reliable percocet prescription. Needless to say, she came to the ED because her pain wasn’t getting any better and now she was having increasing lower abdominal pain with high fevers. In the ED she was febrile (T: 104.5) and tachycardic (HR: 120s), but her BP was normal. She ended up having a WBC: 17k/mm3, bands: 20% and a pretty nasty UTI. Her pain persisted and we ended up doing a CT abd/pelvis with contrast to see if she had anything brewing. From the images below you can see that she had bilateral tubo-ovarian abscesses causing bilateral hydronephrosis seen on CT and confirmed with ultrasound. She was started on ampicillin, clindamycin and gentamicin and her abscesses were drained with CT guidance, yielding 400cc of thick, brown, purulent fluid. Yum
Up to one half of all cases of tubo-ovarian abscesses occur in patients with a history of pelvic inflammatory disease (PID). The theoretical etiology of tubo-ovarian abscesses is thought to revolve around an ascending infection arising in the lower reproductive tract, into the uterus and subsequently the fallopian tubes and ovaries. While Neisseria gonorrhea and Chlamydia trachomatis are commonly associated with PID, TOAs are typically polymicrobial and rarely grow either chlamydia or gonorrhea when cultured. As with most pelvic pathology, ultrasound remains the initial diagnostic modality of choice for tubo-ovarian abscesses to best visualize the upper reproductive tract. Ultrasound remains very specific (86-98%), whereas the sensitivity ranges between 56-93%. There is evidence however that computed tomography of the pelvis with contrast may provide better sensitivity than ultrasound in evaluation of TOAs. In the Emergency Department, a triple coverage antibiotic regimen (i.e. ampicillin/clindamycin/gentamicin) should be initiated despite whether the patient is going to need surgical exploration, percutaneous abscess drainage or conservative management. If the patient’s clinical status has either worsened or not improved after 48-72 hours the gynecologist will likely proceed with minimally invasive drainage procedures that have become more readily available, similar to our case.
Post by: Terrance McGovern DO, MPH (@drtmcg13)