Digoxin abortion gone awry….or did it?

Emergency medicine has to be one of the most diverse fields of medicine out there.  Each day is a whirlwind of activity and patients, ranging from cardiac arrests down to the broken fingernail.  Not only are we responsible for the most critically ill, the walking wounded and the patients that have nowhere else to go, but also are faced with the complications encountered in the outpatient setting.  This could be a patient fresh from the chiropractor that is having neck pain, can’t move their arm and now have a carotid dissection; or a patient from a outpatient surgi-center that had local anesthesia but is now seizing; or in the case below a patient that underwent an elective abortion and now is hypotensive and bradycardic.

A 19-year-old female at 20 weeks gestation who had just underwent part 1 of a two day late term elective abortion presents with a syncopal event about 2 hours after the procedure.  Her vital signs at the time were BP: 60/palp, HR: 40bpm, RR: 16, O2: 100% RA and T: 98.7.  After a liter of normal saline her blood pressure and heart rate both normalized (BP:120/70, HR:70s)

So what happened?  Since 2013 one of the day 1 medications of late term abortions is trans-vaginal Digoxin that is delivered either intrafetally or intraplacentally.  The dose is typically 1-3 mg and in this case the patient received a dose of 2 mg.  Initially they drew a dig level, so let’s think about this. You have a post procedural syncope, with a patient still in the clinic 2 hours after the treatment.  You would have to believe that they were concerned about sending her home, she is hypotensive and bradycardic.  Digoxin is used to increase inotropy, thus improving cardiac output. It is doubtful this young healthy female patient, would present with hypotension in this setting. Also the dig level was drawn within first 3 hours of administration and had a level of 5. As you know Dig has a large volume of distribution and levels should be drawn after 6 hours of administration. Also her symptoms improved with IVF, and the only thing they reported were questionable T-wave inversions in lateral leads as the only EKG abnormality, this is after her symptoms resolved. Dig toxicity can present with multiple EKG abnormalities: T-wave changes, short QT, St-scooping, AV blocking, VT, VF, and most commonly PVC’s, and various conduction abnormalities. The center did not transmit EKG.

Her Dig level before they gave her Digibind, was 1.3. The discussion consensus amongst the NYPCC toxicologists was clear on not giving Digibind in this setting; just observe the patient on tele, repeating EKG, and discharging the next morning.  The patient more likely was having anxiety around her procedure and suffered a vasovagal event, that improved with IVF. The patient was fine and went to clinic next day for termination of pregnancy.

There are plenty of complications that can occur after abortions, whether they are infections, retained products of conception, DIC, amniotic fluid embolisms and as described above, aberrant delivery of abortifacient medications.  Besides the historical use of mechanical means of fetal termination, there are pharmacologic medications as well; most commonly intracardiac KCl and intra-fetal/intra-amniotic digoxin.  As you might expect, delivery of these medications could inadvertently end up being maternally injected and will present as though they are hyperkalemic or having acute digoxin toxicity.  The management of both are the same as we typically would proceed with.  Just knowing that these are potential methods that are used for abortions may give you an extra consideration if one of these patients presents to your ED.

Post by: Dr. Daniel Poor, MD

Lunate and perilunate dislocations

A weekend warrior trying to finish up painting that last side of the house takes a tumble off his ladder and lands on his left hand.  He has a palpable deformity on the volar aspect of the distal radius and painful active and passive ROM but is otherwise neurovascularly intact with no median nerve neuropathy.  The following x-ray is obtained:

Lunate dislocationSp splint

You realize something is not where it’s supposed to be!  The patient has a lunate dislocation to the point where it has migrated proximally to the forearm.  After attempts at closed reduction by the Orthopedist, a CT is obtained which shows associated triquetral fracture and improved position of the lunate.  The patient is admitted and scheduled for open reduction and repair of intercarpal ligaments in the OR.

Lunate and perilunate dislocations come in a variety of shapes and sizes but the orthopedists organize them into 4 different stages of instability that we’ll go over here.


Stage 1 instability: Scapholunate dissociation 


Typically these patients FOOSH’d onto their wrist sustaining the injury with minimal swelling and pain on physical exam.  On xray we are looking for widening of the scapholunate space of > 2-4mm which is our indication that there has been disruption of the ligament.  You’ll hear the term, the “Terry Thomas” sign to describe the gaping of the metacarpals similar to his teeth.  Depending on the orthopedist these can be managed conservatively with a sugar tong splint or operatively.

terry thomas


Stage 2 instability: Perilunate dislocation 

These injuries will typically be a higher mechanism of injury with more significant physical exam findings than the stage 1’s we just discussed.  On x-ray you’ll notice that the lunate remains aligned with the distal radius while the remaining carpal bones are displaced, usually dorsally.  Most of the time these are going to need a CT to look for any radiooccult fractures of the scaphoid and radial styloid.  These will need operative management to prevent any of the nasty sequelae of median nerve palsy, compartment syndrome, long term wrist dysfunction, etc.

stage2


Stage 3 instability: Midcarpal dislocation


These are going to have a similar mechanism of injury but result in disruption of the triquetrolunate ligament or a triquetral fracture. The radiographs will show neither the capitate or lunate aligned with the distal radius.  You’re going to need ortho for this one.

midcarpal


Stage 4 instability: Lunate dislocation

These aren’t known to be the most common, but they are more severe.  The differentiating factor between this and a perilunate dislocation is that the lunate and distal radius articulation is preserved in perilunate dislocation, but not so in lunate dislocations.  On the AP film you’ll see the “piece of pie” sign (below, left) and on the lateral you’ll see the “spilled teacup” (below, right).  This is yet another one that you’re going to get ortho involved with pretty early on for an urgent reduction and operative management.

spilled pie

ct lunate

We talk a lot about those pesky radiooccult scaphoid fractures and have seen enough distal radius fractures to make us physically ill, but there’s a lot more that can go wrong in the wrist.  These are, for the most part, relatively apparent injuries that have devastating consequences if missed.  So get ortho involved early in these cases so the patient can receive the treatment they need.

Post by: Katrina D’Amore DO, MPH

Throwin’ shade at the POKER Trial

There’s been a lot of chatter in the twitterverse surrounding the recent release of the POKER Trial out of Australia comparing ketofol with propofol for procedural sedation.  Their primary outcomes were looking at respiratory complications, including apnea, desaturation or hypoventilation; with secondary outcomes of hypotension and patient satisfaction.  They report “ketofol and propofol resulted in a similar incidence of adverse respiratory events requiring intervention by the sedating physician.” While this is true based on their data, when you start breaking down the airway interventions, propofol did require more instances of the patient requiring assisted ventilation with a BVM.  Call me crazy, but to me that seems a little more of an intervention than just turning up the oxygen flow on the nasal cannula.  Propofol also had a greater rate (8%) of hypotension (SBP<90) when compared to ketofol (1%), and while there were no clinically significant outcomes related to this hypotension, I think it’s still important to note.  It seems like a lot of shade is being thrown (definition here) at ketofol after this trial, but I haven’t closed the door on ketofol yet.  I would still give ketofol a chance, I much prefer not having to bag my shoulder reductions as the propofol wears off and while a BP of 70/40 may not stroke them out in front of you, it still gets my heart rate up a bit.

Post by: Terrance McGovern DO, MPH (@drtmcg)

Blunt chest trauma

Being in even the most benign car accident imaginable, can be stressful for patients.  Inherently, if they have any chest pain they’re going to be convinced that they’ve sheared their aorta right off its hinges.  While that may be of concern to them, we are pretty certain that their aorta is still intact if they still are alive, but did they sustain a cardiac contusion? How do we figure out if they had one?  And what the heck do we do with them if they did in fact have a cardiac contusion?

1) What are we concerned about in blunt chest trauma?
There are many clinically significant injuries possible in the setting of blunt chest trauma. One that comes to mind is the nebulus diagnosis of “cardiac contusion.”  A lot of the controversy and uncertainty comes from the unclear definition of cardiac contusion which seems to encompass things like myocardial rupture, valvular injury, arrhythmias, cardiac dysfunction, etc. In my mind these types of patients would be more clinically apparent so we’ll focus on the patients who may appear well or relatively so.

2) Do we need to get a troponin in blunt chest trauma?
The answer is yes and no. There is a “guideline” answer and a practical one.
The guideline answer is yes. The 2012 EAST practice guideline for blunt trauma recommends BOTH an EKG and troponin. They state based on their references that a normal EKG in blunt chest trauma has a NPV of 95%. This increases to 100% with a normal troponin. There are several studies that support the use of troponin in this setting and there are instances when EKGs may be normal with a positive troponin. One recent study showed a troponin at 24 hours had 100% NPV for severe cardiac injury.
But the practical answer may be no. There are other studies that are less optimistic regarding the sensitivity and specificity and discourage the use of troponin as a gold standard for diagnosing cardiac contusion from blunt trauma. Another study showed that positive troponins were not a strong predictor of abnormalities on echocardiogram. So getting a troponin may not even matter. However other studies suggested that a positive troponin may be indicative of cardiac contusion or underlying cardiac issue, which brings us to our next question.

3) What do we do with a positive troponin in blunt chest trauma?
One of the arguments against getting a troponin is not knowing what to do with it. If it is negative can they go home? If it’s positive do they need to stay? A 2013 prospective study out of Iran does not recommend troponin as a gold standard in cardiac injury but does encourage intensive cardiac monitoring if an elevated troponin is found. Another study showed that elevated troponin was linked to arrythmias during the patients stay.  So this would suggest admission and tele monitoring for a patient that may have otherwise gone home.

4) Does this change the patients outcome?
Probably not. Three older studies looked at outcomes of patients with cardiac contusions and they really have no long term sequelae and do well.

What’s the bottom line?
Being in a trauma center I would follow the trauma guidelines of getting both an EKG and troponin in the setting of blunt chest trauma. If this is negative with a negative EKG and the patient appears well clinically then likely discharge. However if they have an isolated positive troponin then I would consider admission for 24 hour monitoring for arrythmias with a consideration for inpatient echocardiogram with a reassuring knowledge that they will almost absolutely do well long term.

Post by: Dr. Jordan Jeong, DO (@jeongjom)